Health promotion of frail elderly individuals and at risk of frailty

Silva, Cynthia Roberta Dias Torres; Carvalho, Khelyane Mesquita de; Figueiredo, Maria do Livramento Fortes; Silva-Júnior, Fernando Lopes; Andrade, Elaine Maria Leite Rangel; Nogueira, Lydia Tolstenko

doi:10.1590/0034-7167-2018-0575

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Revista Brasileira de Enfermagem

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Sumário

REVIEW • Rev. Bras. Enferm. 72 (suppl 2) • Nov 2019 • https://doi.org/10.1590/0034-7167-2018-0575 copy

Health promotion of frail elderly individuals and at risk of frailty

Promoción de la salud de ancianos frágiles y con riesgo de fragilidad

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To identify interventions for the health promotion of frail elderly individuals and those at risk of frailty.

Method:

Integrative review of the literature performed in the following databases: LILACS, CINAHL, MEDLINE, Web of Science, COCHRANE and Scopus, using the

Descriptors:

“frail elderly”, “aging”, “health services for the aged” and “health promotion” combined with Boolean operators “AND” and “OR”.

Results:

Randomized controlled clinical trials (RCTs) classified as level of evidence II represented 82.6% of studies. Interventions were analyzed according to the following categories: Interventions for the elderly at risk of frailty and Interventions for the frail elderly.

Conclusion:

The following interventions were identified: educational multiprofessional group meetings, physical training, home visit/home care program, nutrition assessment and supplementation, health maintenance programs and cognitive training; models/programs of management and monitoring, use of assistive technology devices and hospitalization program for geriatric rehabilitation.

Descriptors
Frail Elderly; Frailty; Aging; Health Services for the Aged; Nursing Care

N	DESIGN	LOCATION/POPULATION	INTERVENTION/ FOLLOW-UP TIME	OUTCOME
Intervention aimed at the elderly at risk of frailty
A1⁽¹⁷17 Dungan JM, Brown AV, Ramsey MA. Health maintenance for the independent frail older adult: can it improve physical and mental well-being? J Adv Nurs [Internet]. 1996 [cited 2018 May 24];23(6):1185-93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8796467 https://www.ncbi.nlm.nih.gov/pubmed/8796... ⁾	Quasi-experimental	USA/59 independent frail elderly.	Health maintenance program for regular exercise practice, teaching on health and physical and mental wellbeing/ six months.	Clinical improvement in all measurements with emphasis on systolic blood pressure and range of motion in the right ankle, and better indices of self-esteem and life satisfaction.
A2⁽¹⁸18 Bouman A, van Rossum E, Evers S, Ambergen T, Kempen G, Knipschild P. Effects on health care use and associated cost of a home visiting program for older people with poor health status: a randomized clinical trial in the Netherlands. J Gerontol A Biol Sci Med Sci [Internet]. 2008 [cited 2018 May 24];63(3):291-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18375878 https://www.ncbi.nlm.nih.gov/pubmed/1837... ⁾	RCT	Netherlands/330 elderly people with health problems.	Home visits and multidimensional geriatric evaluation/18 months.	No effect on the use of health services by the elderly, and low chance of being cost-effective.
A3⁽¹⁹19 Barrios MDM, Pardo LHS, Ceballo GC. Fragilidad em el adulto mayor: intervención educativa sobre los cuidados em el anciano. MEDICIEGO [Internet]. 2010 [cited 2018 May 24];16(Supl.2). Available from: http://www.bvs.sld.cu/revistas/mciego/vol16_supl2_10/pdf/t5.pdf http://www.bvs.sld.cu/revistas/mciego/vo... ⁾	Quasi-experimental	Argentina/110 frail elderly.	Home visit/-	Higher level of knowledge on adequate nutrition, benefits of physical exercise and preventive measures for falls.
A4⁽²⁰20 Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada):a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci [Internet]. 2010 [cited 2018 May 24];65B(1):107-18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19414866 https://www.ncbi.nlm.nih.gov/pubmed/1941... ⁾	Quasi-experimental	Canada/1,501 elderly individuals at risk of functional decline.	Program for maintenance of autonomy (PRISMA)/four years	Fewer cases of functional decline and prevalence of unmet needs, higher satisfaction and empowerment. Lower number of visits to emergency rooms and hospitalizations than expected in the experimental cohort.
A5⁽²¹21 Gustafsson S, Wilhelmson K, Eklund K, Gosman-Hedström G, Zidén L, Kronlöf GH, et al. Health-promoting interventions for persons aged 80 and older are successful in the short term- results from the randomized and three-armed elderly persons in the risk zone study. J Am Geriatr Soc [Internet]. 2012 [cited 2018 May 24];60(3):447-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22409735 https://www.ncbi.nlm.nih.gov/pubmed/2240... ⁾	RCT	Sweden/459 independent elderly people in ADL.	Preventive home visits and weekly multiprofessional group meetings with one follow-up home visit/three-months.	Delay of deterioration of ADLs compared to a single preventive home visit.
A6⁽²²22 Gustafsson S, Eklund K, Wilhelmson K, Edberg AK, Johansson B, Kronlöf GH, et al. Long-term outcome for ADL following the health-promoting RCT--elderly persons in the risk zone. Gerontologist [Internet]. 2013 [cited 2018 May 24];53(4):654-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22936539 https://www.ncbi.nlm.nih.gov/pubmed/2293... ⁾	RCT	Sweden/459 independent elderly people.	Preventive home visit and weekly multiprofessional group meetings with one follow-up home visit/one and two years.	Reduction of dependency in ADL after one year. High-level meetings were superior to a preventive home visit. Significant additional effects were observed after two years.
A7⁽²³23 Behm L, Wilhelmson K, Falk K, Eklund K, Zidén L, Dahlin-Ivanoff S. Positive health outcomes following health-promoting and disease-preventive interventions for independent very old persons: long-term results of the three-armed RCT elderly persons in the risk zone. Arch Gerontol Geriatr [Internet]. 2014 [cited 2018 May 24];58(3):376-83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24462053 https://www.ncbi.nlm.nih.gov/pubmed/2446... ⁾	RCT	Sweden/459 independent elderly people in ADL	Preventive home visit and weekly multiprofessional group meetings with one follow-up home visit/one and two years.	Effective in delaying the deterioration of mobility and maintaining health satisfaction for up to two years. High-level meetings appear to have a greater effect than preventive home visits with regard to delaying the deterioration of self-rated health care with sustained effect after one year.
A8⁽²⁴24 Sugimoto H, Demura S, Nagasawa Y, Shimomura M. Changes in the physical functions of pre-frail elderly women after participation in a 1-year preventative exercise program. Geriatr Gerontol Int [Internet]. 2014 [cited 2018 May 24];14 (4):975-82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24299293 https://www.ncbi.nlm.nih.gov/pubmed/2429... ⁾	Clinical trial with parallel groups	Japan/58 elderly (healthy and pre-frail women)	Individual physical exercise program/one year.	Improvements in advancement and retreat time, and five-meter walking time tests in the pre-frail elderly group after the exercise program.
A9⁽²⁵25 Behm L, Eklund K, Wilhelmson K, Zidén L, Gustafsson S, Falk K, et al. Health promotion can postpone frailty: results from the RCT elderly persons in the risk zone. Public Health Nurs [Internet]. 2016 [cited 2018 May 24];33(4):303-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26568469 https://www.ncbi.nlm.nih.gov/pubmed/2656... ⁾	RCT	Sweden/459 independent elderly people in ADL.	Preventive home visit and weekly multiprofessional group meetings with one follow-up home visit/three months, one and two years.	Favorable effects in delaying the progression of subjective frailty (experience/feeling of being frail) measured by fatigue in daily activities for up to one year.
A10⁽²⁶26 Godwin M, Gadag V, Pike A, Pitcher H, Parsons K, McCrate F, et al. A randomized controlled trial of the effect of an intensive 1-year care management program on measures of health status in independent, community-living old elderly: the Eldercare project. Fam Pract [Internet]. 2016 [cited 2018 May 24];33(1):37-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26560094 https://www.ncbi.nlm.nih.gov/pubmed/2656... ⁾	RCT	Canada/236 independent elderly subjects.	Nurse-based program of home care/one year	No impact on the outcomes measured.
A11⁽²⁷27 Serra-Prat M, Sist X, Domenich R, Jurado L, Saiz A, Roces A, et al. Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care: a randomised controlled trial. Age Ageing [Internet]. 2017 [cited 2018 May 24];46 (3):401-407. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28064172 https://www.ncbi.nlm.nih.gov/pubmed/2806... ⁾	RCT	Spain/pre-frail elderly.	Nutritional assessment and physical activity program (aerobic exercises and combined strengthening, balance and coordination exercises)/one year.	Effective in preventing frailty in community pre-frail elderly subjects.
Intervention aimed at the frail elderly
A12(28)	RCT	USA/167 elderly newly admitted to the "personal care at home" by the Long Term Care (LTC) program of the B.C. Ministry of Health.	Program of home care and home visits to devise individualized plans/three years.	Statistically significant differences were found at 24 and 36 months when analyzing participants' survival curves.
A13⁽²⁹29 Leveille SG, Wagner EH, Davis C, Grothaus L, Wallace J, LoGerfo M, et al. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. J Am Geriatr Soc [Internet]. 1998 [cited 2018 May 24];46(10):1191-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9777899 https://www.ncbi.nlm.nih.gov/pubmed/9777... ⁾	RCT	USA/201 elderly people with chronic diseases.	Multicomponent disability prevention and disease self-management program/one year.	Significantly higher levels of physical activity and participation of the elderly center, and significant reductions in the use of psychoactive drugs.
A14⁽³⁰30 Mann WC, Ottenbacher KJ, Fraas L, Tomita M, Granger CV. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly: a randomized controlled trial. Arch Fam Med [Internet]. 1999 [cited 2018 May 24];8(3):210-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10333815 https://www.ncbi.nlm.nih.gov/pubmed/1033... ⁾	RCT	USA/104 frail elderly.	Comprehensive functional assessment and evaluation of the home environment with home environmental interventions (EIs) and assistive technology (AT) devices/18 months.	Frail elderly subjects have experienced functional decline over time. The results indicated a reduction of the functional decline rate, and reduction of internal and institutional staff costs through a systematic approach to provide EI and AT.
A15⁽³¹31 Dalby DM, Sellors JW, Fraser FD, Fraser C, Van Ineveld C, Howard M. Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial. CMAJ [Internet]. 2000 [cited 2018 May 24];162(4):497-500. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10701382 https://www.ncbi.nlm.nih.gov/pubmed/1070... ⁾	RCT	Canada/142 frail elderly.	Home nursing visits/14 months.	There was no effect on frailty, only vaccination coverage was greatly improved.
A16⁽³²32 Hinkka K, Karppi SL, Pohjolainen T, Rantanen T, Puukka P, Tilvis R. Network-based geriatric rehabilitation for frail elderly people: feasibility and effects on subjective health and pain at one year. J Rehabil Med [Internet]. 2007 [cited 2018 May 24];39 (6):473-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17624482 https://www.ncbi.nlm.nih.gov/pubmed/1762... ⁾	RCT	Finland/741 frail elderly.	Rehabilitation in rehabilitation centers and home visits/ three seven-day hospitalization periods (totaling 21 days) with assessment at one year.	Viable for use with frail elderly and with improvement of subjective health.
A17⁽³³33 Melis RJ, Van Eijken MI, Teerenstra S, Van Achterberg T, Parker SG, Borm GF, et al. A randomized study of a multidisciplinary program to intervene on geriatric syndromes in vulnerable older people who live at home. J Gerontol A Biol Sci Med Sci [Internet]. 2008 [cited 2018 May 24];63(3):283-90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18375877 https://www.ncbi.nlm.nih.gov/pubmed/1837... ⁾	RCT	Netherlands/151 elderly people with cognitive limitations in performing activities of daily living and/or mental wellbeing.	Home visit with multiprofessional geriatric assessment and management (drug adjustment, referrals to specialized services)/six months.	Improvement of functional skills and mental wellbeing of vulnerable elderly. Higher effectiveness of primary care for this population.
A18⁽³⁴34 Van Hout HP, Jansen AP, Van Marwijk HW, Pronk M, Frijters DF, Nijpels G. Prevention of adverse health trajectories in a vulnerable elderly population through nurse home visits: a randomized controlled trial. J Gerontol A Biol Sci Med Sci [Internet]. 2010 [cited 2018 May 24];65(7):734-42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20457579 https://www.ncbi.nlm.nih.gov/pubmed/2045... ⁾	RCT	Germany/651 frail elderly people	Home visits with assessment and individualized nursing interventions and telephone monitoring/18 months.	No beneficial effects in vulnerable and frail elderly in primary care.
A19⁽³⁵35 Parsons M, Senior H, Kerse N, Chen MH, Jacobs S, Vanderhoorn S, et al. Should care managers for older adults be located in primary care? a randomized controlled trial. J Am Geriatr Soc [Internet]. 2012 [cited 2018 May 24];60(1):86-92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22239292 https://www.ncbi.nlm.nih.gov/pubmed/2223... ⁾	RCT	New Zealand/351 elderly individuals at risk of permanent residential care placement.	Three, six, 12, 18, and 24-month care management program.	Reduction of elderly subjects' risk of mortality and of permanent residential care placement.
A20⁽³⁶36 Metzelthin SF, van Rossum E, Hendriks MR, De Witte LP, Hobma SO, Sipers W, et al. Reducing disability in community-dwelling frail older people: cost-effectiveness study alongside a cluster randomised controlled trial. Age Ageing [Internet]. 2015 [cited 2018 May 24];44(3):390-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25566783 https://www.ncbi.nlm.nih.gov/pubmed/2556... ⁾	RCT	Netherlands/346 frail elderly	Home assessment and individualized interdisciplinary care with regular follow-ups/24 months.	No significant differences between groups regarding disability and health-related quality of life. The elderly in the intervention group used more primary care services, but there was no decline in long-term care.
A21⁽³⁷37 Granbom M, Kristensson J, Sandberg M. Effects on leisure activities and social participation of a case management intervention for frail older people living at home: a randomized controlled trial. Health Soc Care Community [Internet]. 2017 [cited 2018 May 24];25 (4):1416-29. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28295847 https://www.ncbi.nlm.nih.gov/pubmed/2829... ⁾	RCT	Sweden/153 frail elderly.	Home visits/three, six, nine and 12 months.	No differences between groups. However, the intervention group performed leisure activities and physical activities to a greater extent in the three-month period.
Intervention aimed at the elderly at risk of frailty and frail
A22⁽³⁸38 Li CM, Chen CY, Li CY, Wang WD, Wu SC. The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized, controlled trial. Arch Gerontol Geriatr [Internet]. 2010 [cited 2018 May 24];50 (1):39-42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20171455 https://www.ncbi.nlm.nih.gov/pubmed/2017... ⁾	RCT	Taiwan/310 pre-frail and frail community-dwelling elderly.	Comprehensive geriatric assessment (CGA) followed by appropriate intervention by medication adjustment, exercise instruction, nutritional support, physical rehabilitation, social worker consultation and referral to specialists/six months.	Favorable outcome in frail and pre-frail elderly because of the frailty status. Patients' frailty status tended to improve at the six-month follow-up, although without statistical significance.
A23⁽³⁹39 Ng TP, Feng L, Nyunt MS, Feng L, Niti M, Tan BY. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med [Internet]. 2015 [cited 2018 May 24];128(11):1225-36. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26159634 https://www.ncbi.nlm.nih.gov/pubmed/2615... ⁾	RCT	Singapore/246 pre-frail and frail elderly.	Nutritional supplementation, cognitive training, physical training, combination treatment and usual care control/zero months, three months, six months and 12 months.	The status and scores of frailty for 12 months were reduced in all groups, including the control, and were significantly higher in groups of nutritional intervention, cognitive intervention, physical intervention and combination treatment. The beneficial effects were observed at three months and six months, and persisted within 12 months of the measurement.

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[1] Corresponding Author: Cynthia Roberta Dias Torres Silva E-mail: cynthiarobertatorres@gmail.com