1. Mobility, frailty and exercise in older patients
Dr Alison Mudge RBWH
ACRA 2018

2. Ageing: challenges to exercise
Either of us could have a heart attack, or develop heart failure
But our rehab considerations might be different
I will want ot fit around work hours and my daughter’s extracurricular requirements;

3. Figure 1. Prevalences—and overlaps—of comorbidity, disability, and frailty among community-dwelling men and women 65 years and older participating in the Cardiovascular Health Study (Ref. 23, reprinted with permission). Percents listed indicate the proportion among those who were frail (n = 368), who had comorbidity and/or disability, or neither. Total represented: 2762 participants who had comorbidity and/or disability and/or frailty. ⁺n = 368 frail participants overall. *n = 2576 overall with 2 or more of the following 9 diseases: myocardial infarction, angina, congestive heart failure, claudication, arthritis, cancer, diabetes, hypertension, chronic obstructive pulmonary disease. Of these, 249 (total) were also frail. **n = 363 overall with an activity of daily living disability; of these, 100 (total) were also frail
From: Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care
J Gerontol A Biol Sci Med Sci. 2004;59(3):M255-M263. doi: /gerona/59.3.M255
J Gerontol A Biol Sci Med Sci | The Gerontological Society of America 3

4. Outline What is frailty? Do frail people exercise?
Can frail people exercise?
Does exercise treat or reverse frailty?
Do frail patients benefit from exercise?

5. Clegg et al Lancet 2013; 381:752-62

6. “DEFICIT ACCUMULATION”
FRAILTY
“FRAILTY PHENOTYPE”
“DEFICIT ACCUMULATION”

7. FRAILTY Shrinking (weight loss) Slowing (gait speed)
Weakness (handgrip)
Exhaustion (report)
Low activity (report)
SCORE 1-5
Humoral factors mediating disease

8. Disability (ADL/IADL)
FRAILTY
Co-morbidities
Disability (ADL/IADL)
Cognitive impairment
Depression
Self-rated health
SCORE 0-1
“Wear and tear”

9. Do frail people exercise?
Data from NHANES 50+ with at least 4 days x 10 hours of accelerometry data and data to compute frailty index
Theou O et al CMAJ 2017; 189:E

10. Do frail people exercise?
Association between sedentary time and mortliaty was greatest in the frailer subgroups
Theou O et al CMAJ 2017; 189:E

11. Can frail people exercise?
RCTs report exercise adherence 47-95%1
Typically 2-3 times /week, minute group sessions, mixed aerobic/resistance/balance
Inconsistent effects on physical activity levels1,2
Supported exercise programs appear to be safe3
1 Dedeyne L et al. Clin Interven Ageing 2017; 12:873-96
2 DeVries NM et al Ageing Res Rev 2012; 11:136-49
3 Gine-Garriga M et al. Arch Phys Med Rehabil 2014; 95:753-69

12. Does exercise treat frailty?
Cesari M et al. J Gerontol A Med Sci Biol Sci 2015; 70 (2):

13. Does exercise treat frailty?
Cesari M et al. J Gerontol A Med Sci Biol Sci 2015; 70 (2):

16. Do frail patients benefit from exercise?
Data from Canadian Study of Health and Ageing longitudinal survey commenced in 1990 and using data from 5 year followup
Age groups are and 75+
Exercise is 3 or more times per week at least walking
Black is death, dark grey worse frailty status, pale grey unchanged and white is improved
Hubbard et al PLoS One 2009; 4(7): e6174

17. Do frail patients benefit from exercise?
Data from Canadian Study of Health and Ageing longitudinal survey commenced in 1990 and using data from 5 year followup
Age groups are and 75+
Exercise is 3 or more times per week at least walking
Black is death, dark grey worse frailty status, pale grey unchanged and white is improved
Hubbard et al PLoS One 2009; 4(7): e6174

18. Exercise interventions
Exercise can improve mobility (eg SPPB, gait speed)
Exercise can improve muscle strength
No convincing evidence for:
ADL/IADL function
social outcomes
mortality
service use or costs
Puts M et al. Age Ageing 2017; 46:
De Labra et al. BMC Geriatrics 2015; 15:154
Gine-Garriga M et al. Arch Phys Med Rehabil 2014; 95:753-69
DeVries NM et al Ageing Res Rev 2012; 11:136-49
Dedeyne L et al. Clin Interven Ageing 2017; 12:873-96
Lozano-Montoya et al Clin Interven Ageing 2017; 12:

19. Take home messages and unanswered questions
Frailty is a useful concept for predicting outcomes
Best measurement is still debated
Frail people can exercise safely but may need extra support
Should we focus on strength, mobility or regular activity?
Frail people can benefit from exercise with improved mobility and strength
Is this different from non-frail patients?
Limited evidence that exercise ‘treats’ frailty
What are the outcomes we should really be measuring?