Stakeholder Panel (Virtual) Meeting: Nutrition and ... · usual care, aerobic physical activity may...

CANADIAN FRAILTY NETWORK (CFN)

Kidd House, 100 Stuart Street, Kingston, ON, Canada, K7L 3N6 • (613) 549-6666, x.7984 • www.cfn-nce.ca

Stakeholder Panel (Virtual) Meeting: Nutrition and Physical Activity

Clinical Practice Guidelines for Older Adults Living with Frailty

Monday June 29th, 2020

10:00am - 12:30pm ET – Nutrition and Combined interventions (nutrition & physical activity) Guidelines Discussion

1:30pm - 4:00pm ET – Physical Activity Guidelines Discussion

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CANADIAN FRAILTY NETWORK (CFN)

Kidd House, 100 Stuart Street, Kingston, ON, Canada, K7L 3N6 • (613) 549-6666, x.7984 • www.cfn-nce.ca

Table of Contents Foreword ................................................................................................................................... 1

Document Navigation ................................................................................................................ 2

Recommendation 1 .................................................................................................................... 3

Recommendation 2 .................................................................................................................... 5

Recommendation 3 .................................................................................................................... 7

Recommendation 4 .................................................................................................................... 9

Recommendation 5 .................................................................................................................. 10

Recommendation 6 .................................................................................................................. 12

Recommendation 7 .................................................................................................................. 14

Recommendation 8 .................................................................................................................. 16

Appendix 1: Stakeholder Participant List.............................................................................. 18

Appendix 2: Evidence to Decision Frameworks (EtDs) for Nutrition, Physical Activity, and Combined Nutrition and Physical Activity Interventions ..................................................... 20

Recommendation 1: Should nutrition interventions be recommended for older adults living with frailty or pre-frailty? ......................................................................................................................... 23

Recommendation 2: Should protein supplementation be recommended for older adults living with frailty or pre-frailty? ......................................................................................................................... 30

Recommendation 3: Should physical activity interventions be recommended for older adults living with frailty or pre-frailty? ................................................................................................................. 35

Recommendation 4: Should aerobic physical activity be recommended for older adults living with frailty or pre-frailty? ......................................................................................................................... 43

Recommendation 5: Should muscle strengthening activities be recommended for older adults living with frailty or pre-frailty? ................................................................................................................. 49

Recommendation 6: Should mobilization or rehabilitation exercises be recommended for older adults living with frailty or pre-frailty? ............................................................................................. 55

Recommendation 7: Should multi-component physical activity interventions be recommended for older adults living with frailty or pre-frailty? .................................................................................... 62

Recommendation 8: Should combined physical activity and nutrition strategies be recommended for older adults living with frailty or pre-frailty? ............................................................................... 70

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Foreword There is an increasing amount of research evidence related to nutritional and physical activity interventions, but this has not been synthesized into evidence-based nutrition and physical activity guidance for older adults living with frailty. The goal of this online meeting is to solicit stakeholder feedback on draft clinical practice guidelines (CPGs) on nutrition and physical activity developed by the Canadian Frailty Network (CFN). The CPGs will provide health care providers with recommendations, which can be incorporated in the care of older adults with frailty living at home, long-term care or in acute care. The CPGs are being developed using the best available evidence. CFN partnered with the McMaster Evidence Review and Synthesis Team (MERST) and the McMaster Institute for Research on Aging (MIRA) to ensure methodological rigour in creation of the CPGs.

CFN wishes to acknowledge MERST for their support throughout this project, specifically Dr. Megan Racey, whose post-doctoral work focused on the development of these guidelines, as well as Dr. Diana Sherifali, Ms. Donna Fitzpatrick-Lewis, and Dr. Muhammad Usman Ali. Additionally, CFN wishes to acknowledge the contribution of the steering committee in the development of these guidelines and drafting of the recommendations: Dr. Danielle Bouchard, Dr. Anik Giguere, Dr. Leah Gramlich, Dr. Jayna Holroyd-Leduc, Dr. Heather Keller, Dr. Ada Tang. Also on behalf of CFN, I would like to thank Dr. Amanda Lorbergs, Dr. Perry Kim, and Dr. Jeanette Prorok for all their work on this project which would not have been possible without their efforts.

Finally, CFN wishes to thank you for your interest in the development of the nutrition and physical activity CPGs for older adults living with frailty and for your participation in the stakeholder virtual meeting. We greatly appreciate your time and feedback.

Dr. John Muscedere

Scientific Director and CEO, Canadian Frailty Network

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Document Navigation

In this document, you will find the recommendations prepared for the Nutrition and Physical Activity Clinical Practice Guidelines for Older Adults Living with Frailty.

There are two nutrition recommendations, followed by five physical activity recommendations, and one recommendation which encompasses both nutrition and physical activity.

The document is structured by recommendation. Each recommendation is followed by a brief evidence summary and a link to the corresponding Evidence to Decision (EtD) table in support of that recommendation (EtD tables are found in Appendix 2, beginning on page 20 of this document; pages 20-21 provide a brief introduction to the EtD tables). Each recommendation section also includes additional comments from the authors of that recommendation.

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Recommendation 1 We recommend nutritional strategies to enhance dietary intake in older adults living with frailty and pre-frailty [strong recommendation; low certainty of evidence].

Summary of the Evidence:

We considered 8 randomized controlled studies (Jong 2000, Latham 2003, Kim 2012, Tieland 2012, Ng 2015, Niccoli 2017, Park 2018, Wu 2018). The interventions studied were as follows: - Single oral dose of Vitamin D versus placebo/usual diet (Latham 2003), Diet supplementation with a commercial formulation (Ng 2015 and Kim 2012), protein supplementation (Tieland 2012, Niccoli 2017, Park 2018) and dietary modification to enhance dietary food value (Jong 2000, Wu 2018). These studies reported a variety of outcomes and to reach our conclusion, the committee evaluated the following. Physical outcomes (Activities of daily living, muscle strength (handgrip & non-handgrip) and appendicular lean mass) were reported in 7 studies and measured at range of 4 to 24 weeks. There was a positive effect of moderate certainty. Mobility (gait speed, timed up & go, chair sit & stand, balance, short physical performance battery) was reported in all 7 studies and measured at a range 4 weeks to 24 weeks. There was a positive effect of moderate certainty. Effect on body weight and body mass index were reported in 4 studies as measured at a range of 12 weeks to 24 weeks. On aggregation, a statistically significant difference in these measures was not found. Frailty measurement (Cardiovascular Health Study, Korean Longitudinal Study, Fried) was reported in 4 studies and measured at a range 12 weeks to 24 weeks. Overall, there was a reduction in the levels of frailty with moderate certainty. Effect on quality of life was reported in 1 study as measured at 24 weeks. A statistically significant effect was not observed. The impact on caloric intake was reported in 5 studies as assessed at 12 to 24 weeks. On aggregate there was not a statistically significant change in the intake of calories per day. The risk of bias was serious for all of the measures above with the exception of quality of life.

View Evidence-to-Decision Table supporting this recommendation. Additional comments/considerations provided by recommendation authors: Values/preferences: In arriving at our recommendation, we considered the evidence for effect, feasibility and acceptability of the interventions. We prioritized physical outcomes, impact on function and impact on frailty as key criteria.

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Risks/limitations and need for further evidence: Our recommendation is limited by the low quality of evidence and heterogenous interventions in the studies included. We were not able to evaluate costs and the ability to implement nutritional interventions in people with food insecurity. Across the studies it is likely that the usual care or standard care diets varied due to the different settings of the studies and this needs to be considered in evaluating the evidence. The impact of the intervention in those at highest risk with respect to malnutrition needs to be further investigated. In addition, the duration of follow-up was relatively short and a longer study duration may have modified the effect. Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required.

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Recommendation 2 We suggest that older adults living with frailty or pre-frailty consume protein fortified foods/supplements to enhance dietary intake [weak recommendation; low certainty of evidence].

Summary of the Evidence: We considered 5 randomized controlled studies (Kim 2012, Tieland 2012, Niccoli 2017, Park 2018, Wu 2018) with a total enrolment of 344 participants. All of the studies had less than 50 subjects in the intervention arms and there was serious risk of bias across all the studies. In 4 of the studies, the protein supplementation administered was: Kim 2012 - 25g protein/day, Tieland 2012 - 30g protein/day; Niccoli 2017 - 24g of whey protein/day, Wu 2018 – 16d/day of soy protein. In Park 2018, the intervention subjects were assigned to two different levels of protein per day, 1.2 or 1.5 g protein/day but the actual amount of additional protein was not recorded. The protein content of diets in the control groups ranged from 0.8g/kg/day to 1.05g/kg/day. These studies reported a variety of outcomes and to reach our conclusion, the committee evaluated the following. Physical outcomes (activities of daily living, muscle strength (handgrip & non-handgrip), appendicular lean mass) were reported in the 5 studies and assessed at a range of 4 to 24 weeks. On aggregation, there was a positive effect of moderate certainty. Mobility (gait speed, timed up & go, chair sit & stand, balance, short physical performance battery) were reported in the 5 studies and assessed at a range of 4 to 24 weeks. On aggregation, there was a positive effect of moderate certainty. Body weight and body mass index were reported in 3 studies and assessed at a range of 12 to 24 weeks. On aggregation, a statistically significant difference in these measures was not found. Frailty measurement (Cardiovascular Health Study, Korean Longitudinal Study, Modified Fried) was reported in 2 studies and assessed at a mean of 12 weeks. On aggregation, a statistically significant difference in these measures was not found. The impact on caloric intake was reported in4 studies as assessed at 12 to 24 weeks. On aggregate there was not a statistically significant change in the intake of calories per day.

View Evidence-to-Decision Table supporting this recommendation. Additional comments/considerations provided by recommendation authors: Values/preferences: In arriving at our recommendation, we considered the evidence for effect, feasibility and acceptability of the interventions. We prioritized physical outcomes and impact on function and impact on frailty as key criteria.

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Risks/limitations and need for further evidence: Our recommendation is limited by the low quality of evidence and the small size of the studies included. We were not able to evaluate costs and the ability to implement protein supplementation in people with food insecurity. Across the studies it is likely that the usual care or standard care diets varied due to the different settings from which subjects were recruited and this needs to be considered in evaluating the evidence. The post study intake of protein intake varied across studies and we were not able to comment on the optimal amounts; future research should focus on timing and dose of protein intake as well as the relationship of protein to total energy and micronutrient intake. In addition, the duration of follow-up was relatively short and a longer study duration may have modified the effect. Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are required to better evaluate the targets for protein intakes, impact of subject setting, the impact on objective measures of frailty and quality of life.

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Recommendation 3 We recommend that older adults living with frailty or pre-frailty perform physical activity [strong recommendation; moderate certainty of evidence].


Since 1998, physical activity has been evaluated within 26 studies (20 RCTs) conducted across the world (7 in North America, 11 in Asia, 48 in Europe), and that comprised a total of 8022 individuals. Physical activity interventions comprised aerobic physical activity (n = 1 study), muscle strengthening activity (n = 9 studies), mobilization/rehabilitation activities (n = 4 studies), and mixed physical activity (n = 11 studies). Moderate certainty evidence suggests that, compared to minimal contact intervention or usual care, physical activity probably reduces older adults’ level of frailty (large effect, SMD: -1.29; 95% CI: -2.22 to -0.36; 4 randomised studies, 244 participants). This finding is strengthened by additional moderate certainty evidence suggesting that physical activity probably allows reversing frailty (RR: 0.58; 95% CI: 0.36 to 0.93; 4 studies; 2050 participants).

Moderate certainty evidence also suggests that, compared to minimal contact intervention or usual care, physical activity improves mobility (medium effect; SMD: 0.60; 95% CI: 0.37 to 0.83; 19 studies; 1724 participants), activities of daily living (medium effect, SMD: 0.50; 95% CI: 0.15 to 0.84; 9 studies; 910 participants), and quality of life (medium effect; SMD 0.60; 95% CI: 0.13 to 1.07; 6 studies; 500 participants) of older adults living with frailty or pre-frailty. Additionally, moderate certainty evidence suggests that physical activity, compared to minimal contact intervention or usual care, has a small effect on cognitive functions (SMD: 0.35; 95% CI: 0.09-0.61; 5 studies; 377 participants).

However, physical activity may make little or no difference to the fatigue level of older adults living with frailty or pre-frailty. Indeed low certainty evidence suggests that physical activity has no effect on their fatigue level (SMD: -0.27; 95% CI: -0.65 to 0.12). Moreover, it is uncertain whether physical activity reduces older adults’ risks of falling. Indeed, very low certainty evidence suggests there is no effect of physical activity on older adults’ risks of falling (RR: 0.80; 95% CI: 0.51 to 1.26; 4 studies; 724 participants).

Potential harms of physical activities were only included in 12 of the 26 included studies - none of which were serious or significantly different compared with the control group.

It is uncertain whether one type of physical activity is superior to improve patient outcome or limit the use of health services, because we did not look for evidence on the relative effectiveness of the different types of physical activity.

View Evidence-to-Decision Table supporting this recommendation.

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Additional comments/considerations provided by recommendation authors: Implementation: Primary care clinicians should prescribe physical activity to their older patients living with frailty or pre-frailty. Organisations/institutions/healthcare providers that offer services to frail and pre-frail older adults should also ensure that physical activity is prescribed and/or made available to them. The preferences and values of older people living with frailty or pre-frailty should be taken into account when choosing the type of physical activity, whether aerobic physical activity, mobilization or rehabilitation, muscle strengthening, or mixed physical activity.

Population: The average age was from 69 to 84 years old with 68% of participants being women. Frailty status were assessed using a range of outcomes, including Fried, Edmonton, Cardiovascular Health Study, and Study of Osteoporotic Fractures criteria.

Interventions: Of the 26 studies, 12 were delivered using a combination of resistance training, aerobic activities, balance, and rehabilitation activities. The large majority of interventions were supervised by professionals. Most studies were community-based (n=12), the remaining in research centres (n=7), primary care & hospital (n=6), or long-term care settings (n=3). The interventions lasted on average 29 weeks (Only 4 studies with a duration of 9 months or more), performed with an average of 126 minutes of exercise per week with a frequency from 1 to 5 days per week. The intensity of intervention was described as high (n= 1), moderate (n= 7), light (n= 3), and 6 studies did not report intensity.

Outcomes: Mobility outcomes evaluated in these studies commonly included usual and fast gait speed, Timed Up and Go test, and chair-stand tests. Quality of life was most commonly assessed using the SF36. Cognition, activities of daily living, and fatigue were assessed using a range of outcomes.

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Recommendation 4 We suggest that older adults living with frailty or pre-frailty perform aerobic physical activity [weak recommendation; low certainty of evidence].


This intervention was evaluated in a single randomized trial that included 41 participants with frailty. Low certainty evidence suggests that, compared to minimal contact intervention or usual care, aerobic physical activity may improve mobility of older adults living with frailty or pre-frailty (medium effect; SMD 0.71, 95% CI: 0.23 to 1.20). It is uncertain whether aerobic physical activity improves the activities of daily living, cognitive functions, or fatigue of older adults living with frailty or pre-frailty. Indeed, very low certainty evidence suggests that, compared to minimal contact intervention or usual care, aerobic physical activity has no effect on activities of daily living (SMD 0.46, 95%CI -0.03 to 0.94), cognitive function (SMD 0.15, 95% CI -0.50 to 0.80), or fatigue (SMD -0.39, 95% CI -0.87 to 0.09).

The harms of aerobic physical activity are unknown, as this has not been reported in the included study. We found no evidence related to aerobic physical activity interventions for non-community dwelling older adults, such as institutionalized settings, but it is probable that aerobic physical activity can be applied in other settings View Evidence-to-Decision Table supporting this recommendation. Additional comments/considerations provided by recommendation authors:

Population: Participants mean age was 69.8 years old; 83% of participants were women; all were frail. This intervention was tested in community-based older adults

Interventions: Aerobic intervention from which this recommendation was drawn used the following training parameters: twice weekly exercise for 8 weeks, performed on upright stepper with intensity progressing from 40-60% to 60-80% heart rate reserve, and rating of perceived exertion from 11-13 to 13-15 on 6-20 scale. Unable to compare across multiple studies to recommend optimal parameters for aerobic physical activity training.

Outcomes: Physical mobility assessed using 6MWT distance and Timed Up and Go test.

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Recommendation 5 We recommend that older adults living with frailty or pre-frailty perform muscle strengthening activities [strong recommendation; moderate certainty of evidence].


This intervention was evaluated within nine studies with 1058 participants overall. Six of these studies were randomised trials, and three were quasi-experimental trials. These studies were published after 1998; two originated from the US, three from Asia, and four from Europe.

Moderate certainty evidence suggests that, compared to minimal contact intervention or usual care, muscle strengthening probably improves mobility (medium effect; SMD: 0.57; 95% CI: 0.08-1.06; 6 studies; 722 participants). Moderate certainty evidence also suggests that, compared to minimal contact intervention or usual care, muscle strengthening probably allows to reverse frailty status (RR: 0.21; 95% CI: 0.10 to 0.43; 1 study; 70 participants). This could however not be confirmed by the very low certainty evidence that reported no effect of muscle strengthening, compared to minimal contact/usual care, on the level of frailty of older adults (SMD: -0.20; 95% CI: -0.79 to 0.39; 1 study; 65 participants).

Low certainty evidence suggests that muscle strengthening activities may make little or no difference to activities of daily living compared to minimal contact intervention or usual care (SMD: 0.16; 95% CI: -0.05 to 0.37; 2 studies; 362 participants). It remains uncertain whether older adults living with frailty or pre-frailty should perform muscle strengthening activities to improve their cognitive function, quality of life, risks of falling, fatigue, or to reduce their use of healthcare services. Indeed, there is only very low certainty evidence on the effects of muscle strengthening activities on cognitive function (small effect; SMD: 0.45 ; 95% CI: 0.19 to 0.72 ; 1 study; 65 participants), quality of life (SMD: 0.15 ; 95% CI: -0.33 to 0.63 ; 1 study; 70 participants), or risks of falling (RR: 0.78; 95% CI: 0.37 to 1.65 ; 2 studies; 544 participants). We could not find any evidence on the effectiveness of muscle strengthening activities on fatigue level and hospital service use.

Altogether, the findings are demonstrating that some specific elements of mobility would be improved when doing muscle strengthening interventions (i.e., gait speed, TUG) but not all, as most studies report non-significant improvements in comprehensive scores of mobility such as the short physical performance tests).

Of the nine included studies, five did not study adverse effects of muscle strengthening. Of the four that studied adverse effects, a single study (Clegg et al., 2014) reported some adverse effects (falls, admissions to the hospital or care homes) with no significant difference between the intervention and the control groups. View Evidence-to-Decision Table supporting this recommendation.

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Additional comments/considerations provided by recommendation authors:

Population: Participants’ mean age ranged from 74 to 85 years old with 70% of participants being women. Although measured objectively, frailty was categorized using several methods making it hard to really understand participants’ baseline frailty level. Most studies were conducted in the community settings (8/9), but one large RCT study including 278 participants (Faber et al.,2006) was performed in a long-term care setting.

Interventions: The interventions were implemented on average 21 weeks, with an average of 116 minutes of exercise per week. Only one study using muscle strengthening intervention reported frailty status (yes/no) as an outcome. Despite a large RR of 0.21 (0.10-0.43) reported in this study, only grip strength and walking speed were used to quantify frailty status. The study was done over 9 weeks and used resistance bands.

Outcomes: To measure change in frailty status, a range of outcomes were used. Mobility outcomes evaluated in these studies commonly included usual and gait speed, Timed Up and Go test, and chair-stand tests. Cognition, activities of daily living, and fatigue were assessed using a range of outcomes.

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Recommendation 6 We recommend that older adults living with frailty or pre-frailty perform mobilization or rehabilitation exercises [strong recommendation; moderate certainty of evidence].


This intervention was evaluated within four randomised trials, which used a relatively small number of study participants, from 116 to 330 depending on the outcome. Moderate certainty evidence suggests that, compared to minimal contact intervention or usual care, mobilization or rehabilitation exercises probably slightly improve mobility (small effect; SMD: 0.29; 95% CI: 0.17 to 0.42; 3 studies; 330 participants) and activities of daily living (small effect; SMD 0.48; 95% CI: 0.28 to 0.67; 1 study; 182 participants).

Mobilization or rehabilitation exercises may make little or no difference to older adults’ cognitive functions or risks of falling. Indeed, low certainty evidence suggests that, compared to minimal contact intervention or usual care, mobilization or rehabilitation exercises have no effect on cognitive function (SMD: 0.12; 95% CI: -0.10 to 0.34; 1 study; 116 participants) or risks of falling (RR: 0.88; 95% CI: 0.69-1.12; 1 study; 184 participants).

The intervention seems to be safe. A single intervention (Gill 2002) reported adverse events. It found that the rates of possible adverse events of the intervention (falls, musculoskeletal problems, chest pain, angina, death) did not differ significantly between the two groups.

View Evidence-to-Decision Table supporting this recommendation. Additional comments/considerations provided by recommendation authors:

Population: The study populations varied across studies: Brown 2000 and Gill 2002 recruited community-based older adults, whereas Chen 2010 recruited frail older adults admitted to transitional assisted-living and Tsang 2013 recruited frail older adults admitted to hospital-based geriatric services. Study participants were aged between 75 and 85 years, and comprised more women than men (data available from 3 out of the 4 included studies: 114 men/187 women).

Interventions: The interventions differed across studies: Brown 2000 and Gill 2002 studied physical activity combined to rehabilitation, whereas Tsang 2013 and Chen 2010 studied respectively Tai Chi and Yoga. In the Brown 2000 and Gill 2002 studies, physical activity comprised resistance/strength training and balance. Brown 2000 also included flexibility and body handling skills activities. Physical activities were done either daily (Tsang 2013, Gill 2002), or 3 times a week (Brown 2000); one study did not report the frequency of the physical

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activity. The physical activities were reported to have lasted from 10-30 minutes by Gill 2002, to 70 minutes by Chen 2010; one study did not report the length of physical activity. The interventions were implemented during 3 to 8 months before assessment.

The intensity of physical activity within the included studies was light. [Facultative content]: Overall, the studied interventions seemed to be feasible and appropriate, however none of the included studies specifically assessed implementation processes as an objective of their study. Adherence that was reported in two studies (Tsang 2013, Gill 2002) was relatively high, from 73 to 80%. The interventions were also reported to be easy (Brown 2000) and doable without specialised equipment (Brown 2000, Gill 2002), with this last element obvious without the necessity of reporting it for Tai Chi (Tsang 2013) and Yoga (Chen 2010). The costs incurred were reported to be potentially high for staff time (Gill 2002). All interventions were adapted to be done by older adults with limited physical capacities. Satisfaction with the intervention was reported by a single study (Chen 2010), suggesting this aspect would merit further scrutiny in future evaluations. One study (Brown 2000) reports that some of the study participants had too much pain or joint instability to allow them to exercise hard enough for increases in strength to occur in some muscle groups.

Outcomes: Mobility was assessed with the Chair sit & stand test, gait speed, physical performance test, balance test, and timed up & go test. ADLs were assessed in a single study and the authors report a series of their own studies describing the instrument they used, without citing a specific instrument. Cognitive function was assessed in a single study (Tseng 2013) using the Lowenstein Occupational Therapy Cognitive Assessment-Geriatric (LOTCA-G). The incidence of falls seems to have been collected from the medical record of the patient in the single instance when it was an outcome (Gill 2002).

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Recommendation 7 We recommend that older adults living with frailty or pre-frailty perform multi-component physical activity (i.e. incorporating combinations of aerobic, resistance, balance, and flexibility training) [strong recommendation; moderate certainty of evidence].


This intervention was evaluated within 11 randomised and controlled clinical trials, ranging in size from 23 (Daniel et al 2012) to 1635 participants (Liu et al 2018). An additional study (observational cohort study) reported changes in frailty score but it was not considered in developing this recommendation. It was deemed to be high risk of bias, and due to its observational nature that would be considered low evidence and would likely not upgrade any GRADE criteria, it was not included in GRADE evidence rating.

Moderate certainty evidence suggests that mixed physical activity interventions have a large effect on reducing frailty compared to minimal contact intervention or usual care (SMD -1.57, 95% CI -2.57 to -0.57, 3 studies, 199 participants). This finding is strengthened by additional moderate certainty evidence that mixed physical activity can reverse frailty compared to minimal contact/usual care (RR 0.72, 95% CI 0.63 to 0.83, 3 studies; 1981 participants). Moderate certainty evidence also suggests that mixed physical activity interventions have a medium effect size in improvements in mobility (SMD 0.75, 95%CI 0.40 to 1.10, 9 studies, 636 participants).

Similarly, moderate certainty evidence suggest that mixed physical activity, compared to minimal contact intervention or usual care interventions, have medium-sized effects on improving cognition (SMD 0.62, 95% CI 0.12 to 1.11, 2 studies, 180 participants) and quality of life (SMD 0.68, 95% CI 0.16 to 1.21, 5 studies, 430 participants). Moreover, low certainty evidence suggests that mixed physical activity interventions may improve performance of activities of daily living of older adults living with frailty or pre-frailty, compared to minimal contact interventions or usual care (medium effect; SMD 0.64, 95% CI: 0.00 to 1.27, 5 studies, 414 participants).

However, mixed physical activity interventions may make little or no difference to older adults’ risks of falling, emergency visits or hospitalizations. Indeed, low certainty evidence suggests that, compared to minimal contact intervention or usual care, mixed physical activity have no effects on the number of falls they experience (SMD 0.37, 95% CI -0.81 to 0.07, 1 study, 82 participants), on their risks of falling (RR 0.62, 95% CI 0.16 to 2.47), number of emergency visits (SMD: -0.21, 95% CI: -0.65 to 0.23, 1 study, 82 participants), or risks of hospitalizations (RR: 0.52, 95% CI: 0.05 to 5.56, 1 study).

It remains uncertain whether older adults living with frailty or pre-frailty should perform mixed physical activity interventions to reduce their fatigue level. Indeed, there is only very low

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certainty evidence on the effect of mixed physical activity on fatigue levels (SMD -0.23, 95%CI -0.85 to 0.39, 2 studies, 148 participants).

Interventions are generally considered low risk although many studies did not report occurrence of adverse events. Of those that did, events were minor (pain) that were managed by adjusting the training program. Consideration should be placed on the presence of comorbidities that may affect participation, such as rheumatoid arthritis or joint pain. View Evidence-to-Decision Table supporting this recommendation. Additional comments/considerations provided by recommendation authors:

Population: Mean age of samples ranged from 75.9 (Daniel et al 2012) to 84.1 years (Losa-Reyna et al 2019). On average, studies included 69% females, ranging from 52% (Binder et al 2002) to 100% (Kwon et al 2015). Studies included participants with frailty and pre-frailty.

Interventions: Most (7 of 10) studies of mixed physical activity interventions were 12-24 weeks in duration, 1-5 times/week for 60-90 minutes. Intensity of exercise was described to be at moderate levels, although this was commonly not reported (reported in 2 of 7 studies). However, improvements may be seen as little as 6 weeks for twice-weekly 45 minutes of high-intensity exercise (Losa-Reyna et al 2019), or as long as 2 years of moderate-intensity exercise performed 3-4 times/week (Liu et al 2018).

Outcomes: To measure change in frailty status, a range of outcomes were used, including Fried, Edmonton, Cardiovascular Health Study, and Study of Osteoporotic Fractures criteria. Mobility outcomes evaluated in these studies commonly included usual and fast gait speed, Timed Up and Go test, and chair-stand tests. Quality of life was most commonly assessed using the SF36. Cognition, activities of daily living, and fatigue were assessed using a range of outcomes.

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Recommendation 8 We recommend that older adults who are living with frailty or pre-frailty adopt combined physical activity and nutrition strategies [strong recommendation; low certainty of evidence].

Summary of the Evidence: We considered 8 trials including 5 RCTs (Serra-Prat, 2017, Luger, 2016, Kwon, 2015, Tieland, 2012, de Jong, 2000), 2 Case Control Trials (Kang, 2019, Nykanen, 2012) and 1 pilot trial (Yamada, 2012) with a total enrolment of 971 participants. There was serious risk of bias across all studies.

Interventions were undertaken in hospital (Kang2019, Luger 2016) or a research centre (Kwon 2015) or in primary care (Serra-Prat 2017) or in the community (Tieland 2012, Yamada 2-12, de Jong 2000, Nykanen 2012). While 4 of the studies included had a duration of 3 months (Kang 2019, Luger 2016, Kwon 2015, Yamada 2012), 2 studies were 17 and 24 weeks respectively (deJong,200, Tieland 2012) and 2 were 1 year in duration (Nykanen 2012, Serra-Prat 2017).

In 4 studies the nutrition intervention was diet counselling either in person (Serra-Prat 2017, Luger 2016) or via phone (Nykanene2012) or included cooking classes (Kwon 2015). 4 studies included fortified/enhanced foods including whey protein (32gm/d; Kang 2019), or supplements (Tieland 2012; Yamada2012; de Jong 2000). The role of micronutrient (vitamin supplementation) is not addressed in these studies.

The physical activity interventions focused on muscle strengthening in 6 studies (Kang 2019, Luger 2016, Kwon 2015, Tieland 2012, Yamada 2012, Nykanenen 2012) or mixed approaches such as walking (Serra-Prat 2017, de Jong 2000).

These studies reported a variety of outcomes and to reach our conclusion, the committee evaluated the following:

Physical outcomes (activities of daily living, muscle strength (handgrip & non-handgrip), appendicular lean mass) was assessed in 6 studies and there was a positive effect of moderate certainty. Mobility ((gait speed, timed up & go, chair sit & stand, balance, short physical performance battery) was assessed in 6 studies and there was a positive effect of moderate certainty. Frailty was improved (negative association) in 5 studies of moderate certainty. There was no effect on diet quality reported in 2 studies but this was of very low certainty due to inconsistency and imprecision. Quality of life was reported in 3 studies and borderline positive impact was noted of low certainty.

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View Evidence-to-Decision Table supporting this recommendation. Additional comments/considerations provided by recommendation authors: Values/Preferences: In arriving at our recommendation, we considered the evidence for effect, feasibility and acceptability of the interventions. We prioritized physical outcomes, impact on function and impact on frailty as key criteria.

Risks/limitations and need for further evidence: Our recommendation is limited by the low quality of evidence and the diversity diet and physical activity interventions studied. We were not able to evaluate costs and the ability to implement combined approaches. Across the studies it is likely that the usual care or standard care varied due to the different settings from which subjects were recruited and this needs to be considered in evaluating the evidence. In addition, the duration of follow-up was variable ranging from 3-12 months and a more consistently longer study duration may have modified the effect. Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are required to better evaluate the targets for specific nutrient intake and specific activity interventions, impact of subject setting, the impact on objective measures of frailty and quality of life.

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Appendix 1: Stakeholder Participant List Dr. Muhammad

Usman Ali Epidemiologist McMaster University

(MERST)

Ms. Kyla Alsbury PT, PhD Student University of Toronto

Mrs. Marlis Atkins Nutrition Services Director Alberta Health Services

Mrs. Carlota Basualdo-Hammond

Executive Director, Nutrition Services

Alberta Health Services

Prof. Danielle Bouchard Associate Professor UNB

Dr. Stéphanie Chevalier Associate Professor McGill University

Dr. Jennifer Copeland Professor University of Lethbridge

Ms. Donna Fitzpatrick-Lewis Research Coordinator McMaster University

Prof. Anik Giguere Associate Professor Laval University, Quebec city

Ms. Chelsia Gillis PhD Candidate University of Calgary

Dr. Leah Gramlich Professor of Medicine University of Alberta

Dr. Jayna Holroyd-Leduc Professor and Physician University of Calgary

Dr. Lillian Hung Director education CGNA

Dr. Susan Hunter Associate Professor University of Western Ontario

Dr. Scott Kehler Assistant Professor Dalhousie University

Prof. Heather Keller Professor University of Waterloo

Dr. Michelle Kho Associate Professor McMaster University

Dr. Perry Kim Assistant Scientific Director Canadian Frailty Network

Mrs. Julie Lapointe Director of Knowledge Translation Programs

Canadian Association of Occupational Therapists

Dr. Linda Lee Physician Center for Family Medicine Family Health Team

Ms. Andrea Mayo Student Dalhousie University

Dr. Brad Meisner Board Director Representative

Canadian Association on Gerontology

Dr. Manuel Montero-Odasso Professor of Geriatric Medicine

University of Western Ontario

Dr. José Morais Professor McGill University

Ms. Kate Morissette Senior Epidemiologist Public Health Agency of Canada

19

Dr. John Muscedere Scientific Director Canadian Frailty Network

Dr. Alexandra Papaioannou Geriatrician Hamilton Health Sciences

Dr. Carla Prado Professor University of Alberta

Dr. Janet Pritchard Assistant Professor McMaster University

Dr. Jeanette Prorok Interim Manager, Research and KT

Canadian Frailty Network

Dr. Megan Racey Post-doctoral Fellow McMaster University (MERST)

Dr. Hetesh Ranchod Geriatric Medicine Providence Health Care

Dr. Diana Sherifali Lead McMaster University (MERST)

Dr. Liza Stathokostas Research Director Active Aging Canada

Dr. Ada Tang Associate Professor McMaster University

Dr. Olga Theou CRC Physical Activity, Mobility, and Health Aging

Dalhousie University

Mrs. Emma Tittonel Policy Analyst Public Health Agency of Canada (Division of Aging, Seniors and Dementia)

20

Appendix 2: Evidence to Decision Frameworks (EtDs) for Nutrition, Physical Activity, and Combined Nutrition and Physical Activity Interventions

CFN GRADE Evidence to Decision Frameworks (EtDs) for Nutrition, Physical Activity and Combined Nutrition and Physical Activity Interventions

Developed by: Mohammad Usman Ali, MD and the McMaster Evidence Review and Synthesis Team (MERST)

Overview of the Problem:

Frailty is a leading contributor to functional decline and early mortality in older adults, but it is not a natural outcome of aging (1). Over 1.5 million Canadians are currently diagnosed as medically frail and this number is expected to rise to over 2 million in the next 10 years (2). Frailty is characterized by reductions in physiologic reserve and a reduced ability to respond to stress (3). It is not a specific medical condition or disability, but rather frailty is a syndrome resulting from multiple factors and impairments that can reduce an individual’s functional ability. Older adults with frailty are at an increased risk for adverse outcomes such as falls, mobility decline, hospitalization, and death (4). As a syndrome, frailty is poorly understood and under recognized in a healthcare system which focuses on individual diseases, rather than the totality of the person (5). This results in a high consumption of healthcare resources (6), an increased burden on caregivers, and adverse health outcomes for older adults living with frailty (7).

Overview of GRADE Assessment:

We evaluated the certainty of the body of evidence using the Grading of Recommendation, Assessment, Development and Evaluations (GRADE) method (8). GRADE rates the certainty of a body of evidence as high, moderate, low, or very low and ratings are based on an assessment of 5 conditions: 1. methodological quality (risk of bias and limitations in study designs), 2. consistency across direction/size of effect estimates and

21

statistical heterogeneity, 3. directness of the body of evidence to the populations, interventions, comparators and/or outcomes of interest, 4. precision of results (width of 95% confidence intervals), and 5. indications of reporting bias (publication bias). A body of evidence based on RCTs begin with a high certainty rating which may be downgraded if there are serious or very serious concerns across the studies related to one or more of the five domains.

Overview of GRADE Evidence to Decision Frameworks:

GRADE Evidence to decision framework (EtDs) provides an explicit, systematic, and transparent approach to support the decision making process and facilitate dissemination of clinical recommendations and guidelines informed through the best available evidence (9, 10). EtDs include three key components:

1. Background information (PICO criteria with a summary of information to understand the question and why a recommendation or decision is needed)

2. An assessment with criteria for making a decision (judgements on key criteria, research evidence to inform each judgement, and any additional considerations that inform or justify each judgement)

3. Conclusions/type of recommendation (reached based on the judgments made for all the criteria).

For more reading and information about GRADE EtDs, please see the associated document with resources on Clinical Practice Guidelines, GRADE, and EtDs.

22

This document contains the EtD Framework for each recommendation, as listed below. Any information that is consistent among recommendations and frameworks will be noted.

List of EtD Frameworks by Recommendation RECOMMENDATIONS FOR NUTRITION INTERVENTIONS ....................................................................................................................... 23

Recommendation 1: Should nutrition interventions be recommended for older adults living with frailty or pre-frailty?............................................................. 23

Recommendation 2: Should protein supplementation be recommended for older adults living with frailty or pre-frailty? .......................................................... 30

RECOMMENDATIONS FOR PHYSICAL ACTIVITY INTERVENTIONS ..................................................................................................... 35

Recommendation 3: Should physical activity interventions be recommended for older adults living with frailty or pre-frailty? ................................................. 35

Recommendation 4: Should aerobic physical activity be recommended for older adults living with frailty or pre-frailty?.......................................................... 43

Recommendation 5: Should muscle strengthening activities be recommended for older adults living with frailty or pre-frailty? ................................................ 49

Recommendation 6: Should mobilization or rehabilitation exercises be recommended for older adults living with frailty or pre-frailty? ..................................... 55

Recommendation 7: Should multi-component physical activity interventions be recommended for older adults living with frailty or pre-frailty? ........................ 62

RECOMMENDATIONS FOR COMBINED NUTRITION AND PHYSICAL ACTIVITY INTERVENTIONS .............................................. 70

Recommendation 8: Should combined physical activity and nutrition strategies be recommended for older adults living with frailty or pre-frailty? ..................... 70

23

Recommendations for Nutrition Interventions

Recommendation 1: Should nutrition interventions be recommended for older adults living with frailty or pre-frailty? Population:

Older adults aged ≥ 65 years with frailty / pre-frailty assessed using an established criteria or tool

Objective: Research highlights that frailty progression can be slowed and is potentially reversible through nutrition interventions (1). However, it is still unclear the exact role of nutrition interventions to support older adults with frailty or pre-frailty and there is a need for Clinical Practice Guideline recommendations informed through a comprehensive and systematic search of scientific literature.

Intervention: Any nutrition intervention

Comparison: Treatment as usual, standard care

Main outcomes: Health (body weight and body mass index), mortality, physical (activities of daily living (ADL), muscle strength (handgrip and non-handgrip), and appendicular lean mass), quality of life, health services use, frailty, mobility (gait speed, TUG test, chair sit & stand test, balance test, and SPPB), diet quality (energy intake in kcal), and social/caregiver

Setting: Any setting

Perspective: Population

Decision Domain Judgements Research Evidence Additional Considerations

/Explanations

Prio

rity

of th

e Pr

oble

m

Is the problem a priority?

o No o Probably no o Uncertain o Probably yes Yes o Varies

See ‘Overview of the Problem’ above.

Bene

fits

and

harm

s (s

ee

belo

w) Is there

important uncertainty

o Important uncertainty or variability Relative importance of the main outcomes of interest: We have limited evidence on how

much people value the main outcomes as rankings of relevant

24

about or variability in how much people value the main outcomes?

o Possibly important uncertainty or variability

Probably no important uncertainty of variability

o No important uncertainty of variability

o No known undesirable

Outcome Relative

Importance Certainty of the

evidence (GRADE)

Physical Critical ⨁⨁⨁◯

MODERATE

Mobility Critical ⨁⨁⨁◯

MODERATE

Health Critical ⨁⨁◯◯

LOW

Frailty Critical ⨁⨁⨁◯

MODERATE

Diet Quality Critical ⨁◯◯◯ VERY LOW

Quality of life Critical ⨁⨁⨁◯

MODERATE

outcomes were based on consensus of clinical expert panel. The panel consisted of researchers and clinicians but not other stakeholder groups such as patients.

What is the overall certainty of this evidence?

o No studies o Very low Low o Moderate o High

No data available for mortality, health services use, and caregiver/social outcomes from included studies.

How substantial are the desirable anticipated effects of the intervention?

o Large o Moderate Small o Trivial o Varies o Don’t know

Summary of findings (GRADE):

Outcome

№ of patients Effect

Nutrition Usual care

Absolute (95% CI)

Physical 373 321 SMD 0.16 SD higher (0.02 higher to 0.29

higher)

How substantial are the undesirable anticipated

Trivial o Small o Moderate o Large o Varies o Don’t know

Limited data available on harms. Based on evidence from research, there appears to be more risk of adverse outcomes for older adults with frailty or prefrailty who remain

25

effects of the intervention? Mobility 373 321

SMD 0.15 SD higher (0.001 higher to 0.3

higher)

Health 150 134 SMD 0.18 SD lower (0.51 lower to 0.16

higher)

Frailty 155 100 SMD 0.22 SD lower (0.44 lower to 0.01

lower)

Diet Quality

222 161 SMD 0.1 SD higher (0.47 lower to 0.67

higher)

Quality of life

121 122 SMD 0.12 SD lower (1.39 lower to 1.15

higher)

Harms: Included studies either reported no adverse events or trivial side effects for participants in nutrition intervention arm (i.e. dyspepsia, diarrhoea, and nausea).

malnourished than those who receive nutrition interventions (11).

Does the balance between desirable effects and undesirable effects favour the option of the comparison?

o Favours the option Probably favours

the option o Does not favour either o Probably favours the

comparison o Favours the

comparison o Varies

Valu

es a

nd p

refe

renc

es Is there

similarity about how much people value the main outcomes, including the main

o No o Probably no Uncertain o Probably yes o Yes o Varies

Older adults have identified that their priority is to remain independent and actively contributing to society (12). Based on evidence from qualitative focus group work (7, 13-15):

• Older adults saw a difference in being frail vs identifying as frail and often resisted being identified as frail as it was met with negative perceptions.

Older adults with frailty need person-focused care, rather than disease focused care. The association between frailty and negative outcomes (i.e. falls, disability, hospitalizations, institutionalization, and mortality) has been repeatedly confirmed

26

outcomes, including adverse effects and burden of the intervention?

• While research does not exist on whether patients recognize, accept, or know they are frail themselves, older adults’ perceptions of frailty differ from the definition used in medical literature.

• Older adults who identified as frail believed that frailty was due to factors beyond their personal control, including age, functional limitations, and health conditions.

• Health professionals showed confidence in prevention and management of frailty, they also acknowledged the difficulty of having the right tools to identify people who might benefit, and when intervention would be more useful.

• Older adults had more uncertainties and thought frailty was, at least in part, inevitable and inherent to old age. Some also thought that frailty was the outcome of lifestyles and attitudes throughout life, and that prevention could hardly modify such long term impacts.

• The discrepancy between the clinical understanding of frailty and the way people perceive frailty has important implications for older adult’s wellbeing.

regardless of the tools used for its assessment (7). However, research could not be found about how older adults with frailty may feel about these risks or negative outcomes. In addition, there was no research with older adults and burden of the intervention.

Reso

urce

s

What is the certainty of the evidence of resources requirements (costs)?

No studies o Very low o Low o Moderate o High

We are aware of no studies that report actual costs associated with nutrition interventions in older adults living with frailty or pre-frailty. In addition, it is also unclear from the research who would pay for the interventions. Current research focuses on the cost of treating and managing frailty (16).

Researchers, organizations, and policymakers are calling for more integrated healthcare systems that focus on whole person-centered care, rather than single diseases (16).

Does the cost effectiveness of the option favour the



comparison

We are aware of no evidence specific to cost-effectiveness of nutrition interventions in older adults living with frailty or pre-frailty. However, limited evidence from research suggests that investment in cost for interventions may translate to reduced healthcare costs in long-term (12).

Frailty-related adverse outcomes are associated with substantial resource consumption. The identification of successful interventions, even if initially associated with costs of

27

option or the comparison?

o Favours the comparison

o Varies

implementation, will eventually result into cost savings and represents a priority from the societal and health care systems perspective (7).

Equi

ty

What would be the impact on health equity?

o Increased Probably increased o Uncertain o Probably reduced o Reduced o Varies

Evidence from research identified some key concerns i.e. those without access to grocery stores, food insecurity, or those who are more frail are likely not able to participate in interventions or purchase healthy food, protein foods, and adhere to nutrient-dense diets.

Research also suggests nutrition interventions such protein supplementation to be more effective in older adults with frailty with lower socioeconomic status and education. It is likely that in such conditions older people are more likely to be in a deficit status, which makes the intervention actually necessary and the effect more evident (7).

Approximately 2.4% of older Canadians are estimated to be moderately or severely food insecure with food insecurity being 5 times greater for older adults living in northern Canada compared to central Canada (17). This will likely have a direct impact on older adults with frailty being able to adhere to nutrition interventions.

Acce

ptab

ility

Is the option acceptable to key stakeholders?

o No o Probably no o Uncertain Probably yes o Yes o Varies

Evidence from research suggests that:

• Older adults who have mild frailty feel that accepting help of any kind may indicate the start of dependency and precipitate a decline. Hence, language, context, and wording are important considerations to increase acceptability (12).

• Older adults acceptance of interventions on frailty is enhanced in case of interventions that promote their involvement, empowerment, self-advocacy, resilience and include psychological components (7).

• Similarly, acceptance of interventions on frailty by older adults is enhanced in case of

Differences in cultural preferences concerning aspects that play a central role in some interventions on frailty (like type of patient-care provider relationship, involvement of people's privacy, importance of supervision, etc.) might make acceptability of the same intervention variable across settings and individuals (7). Policy-makers suggested that priority of frailty should be devolved from specialists to a wider healthcare

28

Should nutrition interventions be recommended for older adults living with frailty or pre-frailty?

Type of recommendation

Strong recommendation against the intervention

○

Weak recommendation against the intervention

○

Conditional recommendation for either the intervention or the

comparison ○

Weak recommendation for the intervention

○

Strong recommendation for the intervention

●

interventions that include social connection, rewarding and fun and those in which participants had choice or autonomy over intervention components, activities and timings (7).

• Health professionals felt that it may be too late to reverse frailty in older adults with significant frailty, and believed that the non-frail to pre-frail end of the spectrum was much more amenable to intervention (15).

audience through an awareness raising campaign & training program (18).

Feas

ibili

ty

Is the option feasible to implement?


Nutrition interventions require training, food handling skills, knowledge (food literacy), competency with cooking, ability for long-term care homes and hospitals to source, prepare, and deliver these foods. Research shows that:

• Interventions appear to change behaviour more successfully when they include education components/instruction and provide equipment/resources needed (12).

• Gaps in research for effective interventions tailored to older people with frailty to improve nutrition (12).

• Feasibility of interventions on frailty would come along with the development and adoption of an enhanced holistic patient-centred approach to care with greater integration and coordination across specialties (7).

The research evidence highlighted the current insufficiency of psychological skills and communication abilities among healthcare professionals as a potential barrier to implementation and success of interventions for frailty. And warranted the need of training of healthcare professional in such context as a fundamental requirement to implement interventions for frailty (7).

29

Recommendation We recommend nutrition strategies to enhance dietary intake in older adults living with frailty and pre-frailty [strong recommendation; low certainty of evidence].

Justification There was a positive effect for physical, mobility and frailty outcomes. The health benefits likely outweigh the harms.

Subgroup considerations

None.

Implementation considerations

We were not able to evaluate costs and the ability to implement nutrition interventions in people with food insecurity.

Monitoring and evaluation

Based on the included studies, it is likely that the usual care or standard care diets varied due to the different settings of the studies and this needs to be considered in evaluating the evidence.

Research priorities The impact of the intervention in those at highest risk with respect to malnutrition needs to be further investigated. In addition, the duration of follow-up was relatively short, and a longer study duration may have modified the effect. Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required.

30

Recommendation 2: Should protein supplementation be recommended for older adults living with frailty or pre-frailty? Population:


Objective: Frailty is a multi-component condition which includes physical factors such as reduced handgrip strength and gait speed, previous research found that protein supplementation led to increases in physical performance, including gait speed (1, 19). However, it is still unclear the role of protein supplementation alone as a nutrition intervention to support older adults with frailty and there is a need for Clinical Practice Guideline recommendations informed through a comprehensive and systematic search of scientific literature.

Intervention: Protein supplementation

Comparison: Treatment as usual, standard care





/Explanations

Prio

rity

of th

e Pr

oble

m




31

Bene

fits a

nd h

arm

s (se

e be

low

)

Is there important uncertainty about or variability in how much people value the main outcomes?

o Important uncertainty or variability





Relative importance of the main outcomes of interest:

Outcome Relative


evidence (GRADE)


MODERATE


MODERATE


LOW

Frailty Critical ⨁⨁◯◯

LOW


See comments in ETD framework for ‘nutrition interventions’ above (recommendation 1).



No data available for mortality, quality of life, health services use, and caregiver/social outcomes from included studies.




Outcome


Protein suppl.

Usual care

Absolute (95% CI)

Physical 195 149 SMD 0.16 SD higher (0.01 higher to 0.31

higher)

Mobility 195 149 SMD 0.2 SD higher (0.02 higher to 0.39

higher)

How substantial are the undesirable anticipated effects of the intervention?


32





comparison o Varies

Health 93 84 SMD 0.12 SD lower (0.58 lower to 0.34

higher)

Frailty 98 50 SMD 0.18 SD lower (0.45 lower to 0.09

higher)

Diet Quality


higher)

Harms: Included studies either reported no adverse events or trivial side effects for participants in protein supplementation arm (i.e. dyspepsia, diarrhoea, and nausea). Evidence from research also shows that Protein supplementation had no adverse impact on the serum level of blood urea nitrogen and creatinine clearance (19).

Valu

es a

nd p

refe

renc

es

Is there similarity about how much people value the main outcomes, including the main outcomes, including adverse effects and burden of


In addition to evidence on values and preferences for ‘nutrition interventions’ noted above, no additional evidence specific to protein supplementation was identified and considered for assessment.


33

the intervention?

Reso

urce

s



We are aware of no studies that report actual costs associated with protein supplementation in older adults living with frailty or pre-frailty.

Does the cost effectiveness of the option favour the option or the comparison?




comparison o Varies

In addition to evidence ‘nutrition interventions’ noted above, no additional evidence specific to protein supplementation was identified and considered for assessment.


Equi

ty


o Increased Probably increased o Uncertain o Probably reduced o Reduced o Varies

In addition to evidence for equity on ‘nutrition interventions’ noted above, no additional evidence specific to protein supplementation was identified and considered for assessment.


Acce

ptab

ility



In addition to evidence on acceptability for ‘nutrition interventions’ noted above, no additional evidence specific to protein supplementation was identified and considered for assessment.


34

Should protein supplementation be recommended for older adults living with frailty or pre-frailty?



○


○


comparison ○


●


○

Recommendation We suggest that older adults living with frailty or pre-frailty consume protein fortified foods/supplements to enhance dietary intake [weak recommendation; low certainty of evidence].

Justification There was a positive effect for physical and mobility outcomes. The health benefits likely outweigh the harms; however, our recommendation is limited by the low certainty of evidence and the small size of the studies included.


None.


We were not able to evaluate costs and the ability to implement protein supplementation in people with food insecurity.


Based on included studies, it is likely that the usual care or standard care diets varied due to the different settings of the studies and this needs to be considered in evaluating the evidence. The post study intake of protein intake varied across studies and we were not able to comment on the optimal amounts.

Research priorities

Future research should focus on timing and dose of protein intake as well as the relationship of protein to total energy and micronutrient intake. In addition, the duration of follow-up was relatively short, and a longer study duration may have modified the effect. Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are required to better evaluate the targets for protein intakes, impact of subject setting, the impact on objective measures of frailty and quality of life.

Feas

ibili

ty



In addition to evidence on feasibility for ‘nutrition interventions’ noted above, no additional evidence specific to protein supplementation was identified and considered for assessment.


35

Recommendations for Physical Activity Interventions Recommendation 3: Should physical activity interventions be recommended for older adults living with frailty or pre-frailty? Population:


Objective: Older adults with frailty are at an increased risk for adverse outcomes such as falls, mobility decline, hospitalization, and death. One of the major components of frailty is loss of muscle mass, strength, and/or performance. By addressing these physical deficits and reducing dependence, research suggests that physical activity interventions can not only be used to restore and maintain functional independence in older adults, but may also prevent, delay, or reverse the frailty process (20). However, it is still unclear the specific role of various physical activity interventions for the management of frailty in older population. This warrants the need for Clinical Practice Guideline recommendations for physical activity interventions for older adults living with frailty or pre-frailty informed through a comprehensive and systematic search of scientific literature.

Intervention: Any physical activity intervention

Comparison: Treatment as usual, standard care, minimal contact

Main outcomes: Physical (activities of daily living, falls & fatigue/energy level), quality of life, health services use, frailty, mobility (gait speed, TUG test, chair sit & stand test, balance test, and SPPB), and psychological (cognitive function only)




/Explanations

Prio

rity

of th

e Pr

oble

m




36

Bene

fits a

nd h

arm

s (se

e be

low

)








Outcome Relative


evidence (GRADE)


MODERATE

Activities of daily living

Critical ⨁⨁⨁◯

MODERATE

Cognitive function Critical ⨁⨁⨁◯

MODERATE


MODERATE


MODERATE

Falls Critical ⨁◯◯◯

VERY LOW

Fatigue/Energy level

Critical ⨁⨁◯◯

LOW

Health Service Use Critical ⨁⨁◯◯

LOW



o No studies o Very low o Low Moderate o High

37


o Large Moderate o Small o Trivial o Varies o Don’t know


Outcome


Physical activity

Usual care

Relative / Absolute

(95% CI)

Mobility 946 778 SMD 0.6 SD higher

(0.37 higher to 0.83 higher)


495 415 SMD 0.5 SD higher (0.15 higher to 0.84

higher)

Cognitive function


higher)

Quality of life


higher)

Frailty 120 124 SMD 1.29 SD lower

(2.22 lower to 0.36 lower)

Prevalence of frailty

166/763 (21.8%)

246/775 (31.7%)

RR 0.58 (0.36 to

0.93)

133 fewer

per 1,000 (from 203

fewer



Limited data available on harms.

Research also suggests that in older adults with higher levels of frailty, the physical activity interventions incorporating resistance and balance training exercises need to be supervised and progressed by trained professionals (21).


Favours the option o Probably favours the

option o Does not favour either o Probably favours the

comparison o Favours the comparison o Varies

38

to 22 fewer)

Incidence of Fall

156/420 (37.1%)

137/304 (45.1%)

RR 0.80 (0.51 to

1.26)

90 fewer

per 1,000 (from 221

fewer to 117 more)

Fatigue level


higher)

Harms: Included studies either reported no adverse events or trivial side effects for participants in physical activity interventions particularly resistance training (i.e. joint pain, muscle ache and fatigue). None of the reported harms were serious or significantly different compared with the usual care group.

Evidence from research shows that exercise programs incorporating resistance training were associated with minor adverse effects mainly transient musculoskeletal pain (21).

39

Valu

es a

nd p

refe

renc

es

Is there similarity about how much people value the main outcomes, including the main outcomes, including adverse effects and burden of the intervention?


In addition to evidence on values and preferences for ‘nutrition interventions’ noted above, no additional evidence specific to physical activity interventions was identified and considered for assessment.

See comments in ETD framework for ‘nutrition interventions’ above.

Reso

urce

s



The evidence on resources requirement for physical activity interventions in older adults living with frailty or pre-frailty is limited. Based on evidence from studies conducted in 1998 and 2009, the costs of care ranged from US $2,000 to $3,500 per participant in the intervention group over 4 to 6 months (22, 23).



o Favours the option Probably favours the



Evidence from research shows that physical activity interventions are likely more cost effective than usual care (19, 22), and investment in cost for interventions translates to reduced healthcare costs in long-term (12, 22).


40

Equi

ty


o Increased o Probably increased Uncertain o Probably reduced o Reduced o Varies

Evidence from research identified some key concerns i.e. those without access to community centres, green space, equipment, or those who are more frail are likely not able to participate in physical activity interventions (7).

Research also suggests that physical activity interventions that require people to move, although effective, might limit mobility of older adults who are more frail, pose challenges to their participation and even confine them at home. The adoption of these interventions might discriminate people according to severity of their frail state, whereas, home-based interventions might lead to fairer distribution of benefits (7).

Focus group research shows that interventions need to be tailored to the individual and culturally adapted to accommodate community needs and preferences (12). This may require trainers or specialized instructors and/or education for healthcare professionals to know how make these accommodations.

Acce

ptab

ility



In addition to evidence for acceptability on ‘nutrition interventions’ noted above, the additional evidence from the research on physical activity interventions showed relatively high adherence (>70%) and suggests that:

• Acceptability of exercise programmes to both professionals involved in care provision and older people receiving the intervention, was affected by concerns about safety and adequacy of the programme, especially when self-directed (18).

• Commitment to group-based and expert-led exercise programmes, when delivered at convenient location, was higher and the intervention more successful compared with self-directed individual-based programmes (18).


41

Should physical activity interventions be recommended for older adults living with frailty or pre-frailty?



○


○


comparison ○


○


●

Recommendation We recommend that older adults living with frailty or pre-frailty perform physical activity [strong recommendation; moderate certainty of evidence].

Justification There was a positive effect for mobility, activities of daily living, cognitive function, quality of life, frailty, and prevalence of frailty outcomes. The health benefits likely outweigh the harms.


None.


Primary care clinicians should prescribe physical activity to their older patients living with frailty or pre-frailty. Organisations/institutions/healthcare providers that offer services to frail and pre-frail older adults should also ensure that physical activity is prescribed and/or made available to them. The preferences and values of older people living with frailty or pre-frailty should be considered when choosing the type of physical activity intervention


Based on included studies, it is likely that the usual care or minimal contact comparison group varied studies and this needs to be considered in evaluating the evidence. In addition, the duration of follow-up was variable ranging from 2-24 months and a more consistently longer study duration may have modified the effect.

Feas

ibili

ty



In addition to evidence for feasibility on ‘nutrition interventions’ noted above, the additional evidence also suggests that most physical activity interventions are easy (24) and doable without specialised equipment (23, 24). Research also highlights the need of facilities to implement group-based supervised interventions (e.g. a gym, dedicated personnel, and devices for monitoring) and provision of adequate specific training to deliver exercise programmes for frail/pre-frail older adults. This will not only guarantee their safety and reduce their reluctance to participate, but also enhance the perception of safe working conditions of those delivering the interventions (7).


42

Research priorities Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are also required to better evaluate the impact of subject setting, relative effectiveness of the different types of physical activity and subsequent health services utilization.

43

Recommendation 4: Should aerobic physical activity be recommended for older adults living with frailty or pre-frailty? Population:


Objective: Older adults with frailty are at an increased risk for adverse outcomes such as falls, mobility decline, hospitalization, and death. One of the major components of frailty is loss of muscle mass, strength, and/or performance. By addressing these physical deficits and reducing dependence, research suggests that physical activity interventions can not only be used to restore and maintain functional independence in older adults, but may also prevent, delay, or reverse the frailty process (20). However, it is still unclear the specific role of aerobic physical activity interventions for the management of frailty in older population. This warrants the need for Clinical Practice Guideline recommendations for aerobic physical activity interventions for older adults living with frailty or pre-frailty informed through a comprehensive and systematic search of scientific literature.

Intervention: Aerobic physical activity


Main outcomes: Physical (activities of daily living, falls & fatigue/energy level), quality of life, health services use, frailty, mobility (gait speed, TUG test, chair sit & stand test, balance test, and SPPB), and psychological (cognitive function only).




/Explanations

Prio

rity

of th

e Pr

oble

m




44

Bene

fits a

nd h

arm

s (se

e be

low

)








Outcome Relative


evidence (GRADE)

Mobility Critical ⨁⨁◯◯

LOW


Critical ⨁◯◯◯

VERY LOW

Cognitive function Critical ⨁◯◯◯

VERY LOW



VERY LOW



o No studies Very low o Low o Moderate o High

No data available on quality of life, frailty, falls, and health services use from included studies.





See comments in ETD frameworks for ‘physical activity interventions’ above (recommendation 3).

45





comparison o Varies


Outcome


Physical activity

Usual care

Relative / Absolute

(95% CI)





higher)

Cognitive function


higher)

Fatigue level


higher)

Harms: No harms data was reported by included studies.

46

Valu

es a

nd p

refe

renc

es



In addition to evidence on values and preferences for ‘physical activity interventions’ noted above, no additional evidence specific to aerobic physical activity was identified and considered for assessment.


Reso

urce

s



We are aware of no studies that report actual costs associated with aerobic physical activity in older adults living with frailty or pre-frailty.






comparison o Varies

In addition to evidence for ‘physical activity interventions’ noted above, no additional evidence specific to aerobic physical activity was identified and considered for assessment.


47

Should aerobic physical activity be recommended for older adults living with frailty or pre-frailty?



○


○


comparison ○


●


○

Recommendation We suggest that older adults living with frailty or pre-frailty perform aerobic physical activity [weak recommendation; low certainty of evidence].

Justification There was a positive effect for mobility outcome. The health benefits likely outweigh the harms; however, our recommendation is limited by the low certainty of evidence, limited number of outcomes reported, and small size of the studies included.


None.


We found no evidence related to aerobic physical activity interventions for non-community dwelling older adults, such as institutionalized settings, but it is probable that aerobic physical activity can be applied in other settings.

Equi

ty





Acce

ptab

ility





Feas

ibili

ty





48


We are unable to compare across multiple studies to recommend optimal parameters for aerobic physical activity training.

Research priorities Further studies including larger groups of patients and longer duration of follow-up are required. Further studies are also required to better evaluate the impact of subject settings, and effect of aerobic physical activity on frailty, quality of life, and health services utilization.

49

Recommendation 5: Should muscle strengthening activities be recommended for older adults living with frailty or pre-frailty? Population:


Objective: Older adults with frailty are at an increased risk for adverse outcomes such as falls, mobility decline, hospitalization, and death. One of the major components of frailty is loss of muscle mass, strength, and/or performance. By addressing these physical deficits and reducing dependence, research suggests that physical activity interventions can not only be used to restore and maintain functional independence in older adults, but may also prevent, delay, or reverse the frailty process (20). However, it is still unclear the specific role of muscle strengthening physical activity interventions for the management of frailty in older population. This warrants the need for Clinical Practice Guideline recommendations for muscle strengthening physical activity interventions for older adults living with frailty or pre-frailty informed through a comprehensive and systematic search of scientific literature.

Intervention: Muscle strengthening activities such as progressive resistance training






/Explanations

Prio

rity

of th

e Pr

oble

m




50

Bene

fits a

nd h

arm

s (se

e be

low

)








Outcome Relative


evidence (GRADE)


MODERATE



LOW

Cognitive function Critical ⨁◯◯◯

VERY LOW

Quality of life Critical ⨁◯◯◯

VERY LOW


MODERATE

Falls Critical ⨁◯◯◯

VERY LOW




No data available on fatigue / energy level and health services use from included studies.




Outcome


Physical activity

Usual care

Relative / Absolute

(95% CI)

51







higher)

Cognitive function


higher)

Quality of life


higher)


(0.79 lower to 0.39 higher)


6/33 (18.2%)

29/33 (87.9%)

RR 0.21 (0.10 to

0.43)

694 fewer

per 1,000 (from 791

fewer to 501 fewer)

Incidence of Fall

102/280 (36.4%)

74/162 (45.7%)

RR 0.78 (0.37 to

1.65)

100 fewer

per 1,000

See comments in ETD frameworks for ‘Physical activity interventions’ above (recommendation 3).





comparison o Varies

52

(from 288

fewer to 297 more)

Harms: Included studies reported trivial side effects for participants in resistance training (i.e. joint pain, muscle ache and fatigue). None of the reported harms were serious or significantly different compared with the usual care group. Evidence from research shows that exercise programs incorporating resistance training were associated with minor adverse effects mainly transient musculoskeletal pain (21).

Valu

es a

nd p

refe

renc

es



In addition to evidence on values and preferences for ‘Physical activity interventions’ noted above, no additional evidence specific to muscle strengthening exercises was identified and considered for assessment.


53

Reso

urce

s



We are aware of no studies that report actual costs associated with muscle strengthening exercises in older adults living with frailty or pre-frailty.






comparison o Varies

In addition to evidence for ‘physical activity interventions’ noted above, no additional evidence specific to muscle strengthening exercises was identified and considered for assessment.


Equi

ty




See comments in ETD frameworks for ‘physical activity interventions’ above (recommendation 3)

Acce

ptab

ility





Feas

ibili

ty





54

Should muscle strengthening activities be recommended for older adults living with frailty or pre-frailty?



○


○


comparison ○


○


●

Recommendation We recommend that older adults living with frailty or pre-frailty perform muscle strengthening activities [strong recommendation; moderate certainty of evidence].

Justification There was a positive effect for mobility, cognitive function, and prevalence of frailty outcomes. The health benefits likely outweigh the harms.


None.


Primary care clinicians should prescribe muscle strengthening activities to their older patients living with frailty or pre-frailty. Organisations/institutions/healthcare providers that offer services to frail and pre-frail older adults should also ensure that such training exercises are prescribed and/or made available to them.



Research priorities Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are required to better evaluate the role of muscle strengthening activities in older adults with frailty to improve their cognitive function, quality of life, risks of falling, fatigue, or to reduce their use of healthcare services.

55

Recommendation 6: Should mobilization or rehabilitation exercises be recommended for older adults living with frailty or pre-frailty? Population:


Objective: Older adults with frailty are at an increased risk for adverse outcomes such as falls, mobility decline, hospitalization, and death. One of the major components of frailty is loss of muscle mass, strength, and/or performance. By addressing these physical deficits and reducing dependence, research suggests that physical activity interventions can not only be used to restore and maintain functional independence in older adults, but may also prevent, delay, or reverse the frailty process (20). However, it is still unclear the specific role of mobilization or rehabilitation exercise interventions for the management of frailty in older population. This warrants the need for Clinical Practice Guideline recommendations for mobilization or rehabilitation exercise interventions for older adults living with frailty or pre-frailty informed through a comprehensive and systematic search of scientific literature.

Intervention: Mobilization or rehabilitation exercises






/Explanations

Prio

rity

of th

e Pr

oble

m




56

Bene

fits a

nd h

arm

s (se

e be

low

)








Outcome Relative


evidence (GRADE)


MODERATE


Critical ⨁⨁⨁◯

MODERATE

Cognitive function Critical ⨁⨁◯◯

LOW

Falls Critical ⨁⨁◯◯

LOW




No data available on quality of life, cognitive function, frailty, fatigue / energy level and health services use from included studies.






57






Outcome


Physical activity

Usual care

Relative / Absolute

(95% CI)





higher)

Cognitive function


higher)

Incidence of Fall

51/92 (55.4%)

58/92 (63.0%)

RR 0.88 (0.69 to

1.12)

76 fewer

per 1,000 (from 195

fewer to 76 more)

Harms: Included studies reported trivial side effects i.e. musculoskeletal problems for participants in intervention

58

arm. None of the reported harms were serious or significantly different compared with the usual care group.

Valu

es a

nd p

refe

renc

es



In addition to evidence on values and preferences for ‘physical activity interventions’ noted above, no additional evidence specific to mobilization or rehabilitation exercises was identified and considered for assessment.


59

Reso

urce

s



The costs incurred for mobilization or rehabilitation exercises were reported to be potentially high for staff time (23). The total cost of the intervention in 1998-2000, including the cost of staff time spent in intervention activities, the cost of equipment and supplies, and consultant fees, was an average of US $2,000 per participant in the intervention group over 6 months (23).






In addition to evidence for ‘physical activity interventions’ noted above, no additional evidence specific to mobilization or rehabilitation exercises was identified and considered for assessment.


Equi

ty





Acce

ptab

ility





Feas

ibili

ty





60

Should mobilization or rehabilitation exercises be recommended for older adults living with frailty or pre-frailty?



○


○


comparison ○


○


●

Recommendation We recommend that older adults living with frailty or pre-frailty perform mobilization or rehabilitation exercises [strong recommendation; moderate certainty of evidence].

Justification There was a positive effect for mobility and activities of daily living outcomes. The health benefits likely outweigh the harms.


None.


Organisations/institutions/healthcare providers that offer services to frail and pre-frail older adults should ensure that mobilization or rehabilitation exercises are prescribed and/or made available to them.


Mobilization or rehabilitation exercises may make little or no difference to older adults’ cognitive functions or risks of falling. Based on included studies, it is likely that the usual care or minimal contact comparison group varied studies and this needs to be considered in evaluating the evidence. In addition, the duration of follow-up was variable ranging from 3-8 months and a more consistently longer study duration may have modified the effect.

61

Research priorities Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are required to better evaluate the role of mobilization or rehabilitation exercises in older adults with frailty to improve their cognitive function, quality of life, risks of falling, fatigue, or to reduce their use of healthcare services.

62

Recommendation 7: Should multi-component physical activity interventions be recommended for older adults living with frailty or pre-frailty? Population:


Background: Older adults with frailty are at an increased risk for adverse outcomes such as falls, mobility decline, hospitalization, and death. One of the major components of frailty is loss of muscle mass, strength, and/or performance. By addressing these physical deficits and reducing dependence, research suggests that physical activity interventions can not only be used to restore and maintain functional independence in older adults, but may also prevent, delay, or reverse the frailty process (20). However, it is still unclear the specific role of multi-component physical activity interventions for the management of frailty in older population. This warrants the need for Clinical Practice Guideline recommendations for multi-component physical activity interventions for older adults living with frailty or pre-frailty informed through a comprehensive and systematic search of scientific literature.

Intervention: Multi-component (combinations of aerobic, resistance, balance, and flexibility training)






/Explanations

Prio

rity

of th

e Pr

oble

m




63

Bene

fits a

nd h

arm

s (se

e be

low

)








Outcome Relative


evidence (GRADE)


MODERATE



LOW

Cognitive function Critical ⨁⨁⨁◯

MODERATE


MODERATE


MODERATE

Falls Critical ⨁⨁◯◯

LOW



VERY LOW

Health services use


LOW




How substantial are the desirable anticipated

o Large Moderate o Small o Trivial o Varies o Don’t know


Outcome № of patients Effect

64

effects of the intervention? Physical

activity Usual care

Relative / Absolute

(95% CI)

Mobility

337 299 SMD 0.75 SD higher





Cognitive function



Quality of life



Frailty

98 101 SMD 1.57 SD lower



160/730 (21.9%)

217/742 (29.2%)

RR 0.72 (0.63

82 fewer

per 1,000





Favours the option o Probably favours the



65

to 0.83)

(from 108

fewer to 50

fewer)

Falls (Mean number)



Incidence of Fall

3/48 (6.3%)

5/50 (10.0%)

RR 0.62 (0.16

to 2.47)

38 fewer

per 1,000 (from

84 fewer to 147 more)

Fatigue level



Emergency visits (Mean

number)


66


Hospitalization (Events)

1/48 (2.1%)

2/50 (4.0%)

RR 0.52 (0.05

to 5.56)

1/48 (2.1%)

Harms: Included studies either reported no adverse events or trivial side effects for participants in multi-component physical activity interventions (i.e. joint pain, muscle ache and fatigue). None of the reported harms were serious or significantly different compared with the usual care group.

Valu

es a

nd p

refe

renc

es Is there

similarity about how much people value the main outcomes, including the main


In addition to evidence on values and preferences for ‘physical activity interventions’ noted above, no additional evidence specific to multi-component physical activity was identified and considered for assessment.


67

outcomes, including adverse effects and burden of the intervention?

Reso

urce

s



Based on limited evidence from included studies, the total cost of the intervention in 2009, including the cost of care and medical costs, was an average of US $3,500 per participant in the intervention group (22).






Limited evidence from research shows that multi-component physical activity interventions are likely cost effective than usual care (22), and investment in cost for interventions translates to reduced healthcare costs in long-term (22).


Equi

ty



In addition to evidence for ‘physical activity interventions’ noted above, no additional evidence specific multi-component physical activity was identified and considered for assessment.


Acce

ptab

ility





68

Should multi-component physical activity interventions be recommended for older adults living with frailty or pre-frailty?



○


○


comparison ○


○


●

Recommendation We recommend that older adults living with frailty or pre-frailty perform multi-component physical activity (i.e. incorporating combinations of aerobic, resistance, balance, and flexibility training) [strong recommendation; moderate certainty of evidence].

Justification There was a positive effect for mobility, activities of daily living, cognitive function, quality of life, frailty, and prevalence of frailty outcomes. The health benefits likely outweigh the harms.


None.


Primary care clinicians should prescribe multi-component physical activity to their older patients living with frailty or pre-frailty. Organisations/institutions/healthcare providers that offer services to frail and pre-frail older adults should also ensure that such physical activity interventions are made available to them. The preferences and values of older people living with frailty or pre-frailty should be considered when choosing the type and intensity of multi-component physical activity intervention



Feas

ibili

ty





69

Research priorities Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are required to better understand the elements of efficacious multi-component physical interventions and their impact on risk of falling, level of fatigue and use of healthcare services.

70

Recommendations for Combined Nutrition and Physical Activity Interventions

Recommendation 8: Should combined physical activity and nutrition strategies be recommended for older adults living with frailty or pre-frailty? Population:


Objective: Frailty is a multi-component condition which includes physical factors such as reduced handgrip strength and gait speed, therefore, it is important to consider the enhanced impact that adequate nutrition could have on the benefits of physical activity in a frail population (19). Based on the mixed results from existing research looking at physical activity interventions with nutrition supplementation (25), it is still unclear the role of combined approach to support older adults with frailty. This warrants the need for Clinical Practice Guideline recommendations for combined physical activity and nutrition strategies for older adults living with frailty or pre-frailty informed through a comprehensive and systematic search of scientific literature.

Intervention: Physical activity and nutrition combined strategies






/Explanations

Prio

rity

of th

e Pr

oble

m




71

Bene

fits a

nd h

arm

s (se

e be

low

)








Outcome Relative


evidence (GRADE)


MODERATE


MODERATE


LOW


MODERATE


Quality of life Critical ⨁⨁◯◯

LOW

See comments in ETD framework for ‘nutrition interventions’ above.



No data available for mortality, health services use, and caregiver/social outcomes from included studies.




Outcome


Combined approach

Usual care

Relative / Absolute

(95% CI)

Physical 258 256 SMD 0.19 SD higher

How substantial are the undesirable

Trivial o Small o Moderate o Large o Varies

See comments in ETD frameworks for ‘nutrition interventions’ (recommendation 1) and ‘physical

72

anticipated effects of the intervention?

o Don’t know (0.06 higher to 0.32 higher)

Mobility



Health 158 152 SMD 0.05 SD lower





39 / 174 (22.4%)

59 / 185

(31.9%)

RR 0.720 (0.520

to 0.999)

89 fewer

per 1,000 (from 153

fewer to 0

fewer)

Diet Quality



Quality of life


activity interventions’ (recommendation 3) above.





73


Harms: Included studies either reported no adverse events or trivial side effects for participants in combined physical activity and nutrition intervention arm (i.e. back pain in one participant, study withdrawal due to heavy burden or pain by three participants).

Valu

es a

nd p

refe

renc

es



In addition to evidence on values and preferences for ‘nutrition interventions’ noted above, no additional evidence specific to combined approach interventions was identified and considered for assessment.


74

Reso

urce

s



We are aware of no studies that report actual costs associated combined physical activity and nutrition strategies in older adults living with frailty or pre-frailty.






In addition to evidence on ‘nutrition interventions’ and ‘physical activity interventions’ noted above, no additional evidence specific to combined approach interventions was identified and considered for assessment.


Equi

ty




See comments in ETD frameworks for ‘nutrition interventions’ (recommendation 1) and ‘physical activity interventions’ (recommendation 3) above.

Acce

ptab

ility





75

Should combined physical activity and nutrition strategies be recommended for older adults living with frailty or pre-frailty?



○


○


comparison ○


○


●

Recommendation We recommend that older adults who are living with frailty or pre-frailty adopt combined physical activity and nutrition strategies [strong recommendation; low certainty of evidence].

Justification There was a positive effect for physical, mobility, frailty, and prevalence of frailty outcomes. The health benefits likely outweigh the harms; however, our recommendation is limited by the low certainty of evidence and the diversity diet and physical activity interventions studied.


None.


We were not able to evaluate costs and the ability to implement combined physical activity and nutrition strategies in older adults with food insecurity.


Based on included studies, it is likely that the usual care or standard care diets varied due to the different settings of the studies and this needs to be considered in evaluating the evidence. In addition, the duration of follow-up was variable ranging from 3-12 months and a more consistently longer study duration may have modified the effect.

Research priorities Further studies including larger groups of patients, more homogenous interventions and longer duration of follow-up are required. Further studies are required to better evaluate the targets for specific nutrient intake and specific activity interventions, impact of subject setting, the impact on objective measures of frailty and quality of life.

Feas

ibili

ty





76

References

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16. Comans TA, Peel NM, Hubbard RE, Mulligan AD, Gray LC, Scuffham PA. The increase in healthcare costs associated with frailty in older people discharged to a post-acute transition care program. Age Ageing. 2016;45(2):317-20. 17. Leroux J, Morrison K, Rosenberg M. Prevalence and Predictors of Food Insecurity among Older People in Canada. Int J Environ Res Public Health. 2018;15(11). 18. Gwyther H, Shaw R, Jaime Dauden E-A, D’Avanzo B, Kurpas D, Bujnowska-Fedak M, et al. Understanding frailty: a qualitative study of European healthcare policy-makers’ approaches to frailty screening and management. BMJ Open. 2018;8(1):e018653. 19. Apostolo J, Cooke R, Bobrowicz-Campos E, Santana S, Marcucci M, Cano A, et al. Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: a systematic review. JBI Database System Rev Implement Rep. 2018;16(1):140-232. 20. Theou O, Stathokostas L, Roland KP, Jakobi JM, Patterson C, Vandervoort AA, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res. 2011;2011:569194. 21. Skelton DA, Mavroeidi A. Which strength and balance activities are safe and efficacious for individuals with specific challenges (osteoporosis, vertebral fractures, frailty, dementia)?: A Narrative review. J Frailty Sarcopenia Falls. 2018;3(2):85-104. 22. Yamada M, Arai H, Sonoda T, Aoyama T. Community-based exercise program is cost-effective by preventing care and disability in Japanese frail older adults. J Am Med Dir Assoc. 2012;13(6):507-11. 23. Gill TM, Baker Di Fau - Gottschalk M, Gottschalk M Fau - Peduzzi PN, Peduzzi Pn Fau - Allore H, Allore H Fau - Byers A, Byers A. A program to prevent functional decline in physically frail, elderly persons who live at home. 2002(1533-4406 (Electronic)). 24. Brown M, Sinacore DR, Ehsani AA, Binder EF, Holloszy JO, Kohrt WM. Low-intensity exercise as a modifier of physical frailty in older adults. Arch Phys Med Rehabil. 2000;81(7):960-5. 25. Macdonald SH, Travers J, She EN, Bailey J, Romero-Ortuno R, Keyes M, et al. Primary care interventions to address physical frailty among community-dwelling adults aged 60 years or older: A meta-analysis. PLoS One. 2020;15(2):e0228821.

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