PHYSICAL ACTIVITY INTERVENTIONS FOR OLDER ADULTS LIVING WITH FRAILTY: A SYSTEMATIC REVIEW AND META-ANALYSIS PREPARED AND PRESENTED FOR: NUTRITION AND PHYSICAL ACTIVITY CLINICAL PRACTICE GUIDELINES FOR OLDER ADULTS WITH FRAILTY STAKEHOLDER PANEL MEETING JUNE 29 TH , 2020 On behalf of the McMaster Evidence Review and Synthesis T eam: Megan Racey, PhD Mohammad Usman Ali, MD Donna Fitzpatrick-Lewis, MSW 1 Diana Sherifali, PhD Disclaimer: The content of this presentation is confidential and may not be distributed or shared.
SCOPE OF THE PROBLEM 2.0M Canadians Frailty is a leading contributor to functional decline in 10 years and early mortality in older adults. 1.5M Canadians One of the major components of frailty is loss of muscle mass, strength, and/or performance. By addressing these physical deficits and reducing Falls dependence, frailty progression can be slowed and is Mobility decline potentially reversible through physical activity Hospitalization interventions. Death 2
What is the effectiveness of physical activity interventions in older adults (age 65+ RESEARCH years) living with frailty or pre-frailty on clinical, QUESTION patient important, or health utilization outcomes? 3
P – Older adults ≥ 65 years of age with frailty Must have formal definition of frailty using a tool, assessment of frailty, or established criteria 80% of study population is pre-frail or frail I – Any physical activity interventions in all settings from RCTs/CCTs or observational cohorts with a comparison group PICO C – True comparison group, treatment as usual, standard care, minimal contact O – Frailty, Mobility, Psychological (cognitive function only), Health Services Use, Physical, Quality of Life 4
PICO Inclusion / Meta analysis of Screening Data Exclusion data of articles extraction criteria Search strategy Defining strategy Screening and extraction Data analysis 5
DEFINITIONS Intervention Category Aerobic Move large muscles in a rhythmic manner for a sustained period. This type of activity is also called endurance activity. Aerobic activity makes a person's heart beat more rapidly to meet the demands of the body's movement. Examples: Brisk walking, jogging, biking, dancing, swimming, water aerobics, aerobic exercise class, bicycle riding, tennis, golf Muscle-Strengthening Activities that increase skeletal muscle strength, power, endurance and mass using the principles of strength training, resistance training, or muscular strength and endurance exercises. Examples: Exercises using exercise bands, weight machines, hand-held weights, Calisthenic exercises (body weight provides resistance to movement), some yoga and tai chi exercises Mixed (multi-component) Combination of aerobic and muscle-strengthening. Mobilization/Rehabilitation Purpose of intervention was to increase mobilization of the participants. 6
DEFINITIONS Intervention Intensity Resistance/strength training Muscle-strengthening exercises. Light intensity Activities during which one can easily carry a conversation. Moderate intensity Activities that require a medium level of effort. On a scale of 0 to 10, where sitting is 0 and the greatest effort possible is 10, moderate-intensity activity is a 5 or 6 and produces noticeable increases in breathing rate and heart rate. Can also be measured using 70% VO2 max or 80% of peak heart rate. High/strenuous intensity Using the same scale as above, activities that are a 7 or 8 on this scale and produces large increases in a person's breathing and heart rate. Holding a conversation during these activities are difficult. 7
METHODS: CERTAINTY OF EVIDENCE (GRADE APPROACH) Common, systemic and transparent approach to grading certainty of evidence and strength of recommendations Assess based on 5 categories: 1. Risk of bias 2. Inconsistency Results in Certainty of Evidence: 3. Indirectness High, Moderate, Low, or Very Low 4. Imprecision 5. Other consideration RCTs start as high certainty and can be downgraded; Observational studies start as low certainty and can be upgraded 8
METHODS: STATISTICAL ANALYSIS Continuous outcome data using standardized mean difference (SMD) SMDs 0.2-0.5 = small effect SMDs 0.5-0.8 = medium effect SMDs >0.8 = large effect Dichotomous outcome data using risk ratio (RR) Studies assessed for Heterogeneity Multi-level meta-analytic approach 9
RESULTS 10
Records identified Additional records through database identified through other searchings sources N = 11261 N = 0 Records after duplicates removed N = 4668 Records screened Records excluded N = 4450 N = 4668 PRISMA FLOWCHART Full-text articles Full-text articles excluded, with reasons N = 192 assessed for eligibility ------------------------------------------------------------------------ N = 218 Study population (younger than 65, frailty not defined, clinical) (N = 113) Not physical activity intervention (N = 34) Study Design (N = 38) Full-text unavailable (N = 7) Studies included in qualitative synthesis N = 26 (34 articles; 24 RCTS; 2 observational) Studies included in quantitative synthesis (meta-analysis) 11 N = 23
CHARACTERISTICS OF INCLUDED STUDIES Majority of studies were; Location: Asia (n=11), Europe (n=8), North America (n=7) Setting*: Community-based (n=12), Research centre (n=7), Primary care & hospital (n=6), Long-term care home (n=3) Frailty tool: Very diverse including Fried's frailty phenotype, ADL indices, other scales/assessments and mobility measures Duration: 1 to 3 months (n=10), 4 to 8 months (n=12), ≥9 months (n=4) *intervention can be conducted in more than one setting; any and all settings were captured 12
DESCRIPTION OF INTERVENTIONS Category Intensity Frequency Session Duration Delivery • Aerobic: 1 • High/strenuous: 1 • 1-2x/week: 12 • < 15 minutes: 2 • Physiotherapist: 9 • Mixed: 12 • Moderate: 7 • 3-4x/week: 11 • 30-60 minutes: 13 • Fitness instructor /trainer: 7 • Mobilization/ • Light: 4 • ≥4x/week: 2 • >60 minutes: 5 rehabilitation: 4 • Researcher: 3 • Resistance/strength • N/R: 1 • N/R: 6 • Muscle training: 9 • Other: 2 strengthening: 9 • Can't tell: 5 • N/R: 5 N/R = Not Reported 13
RESULTS OVERVIEW | EFFECTIVENESS OF INTERVENTIONS Physical Activity (and by PA intervention category/type) Frailty Mobility Cognitive Function Health Services Use Physical* Quality of Life There was data for all outcomes but not for all PA intervention categories. *Physical outcomes was further broken down into ADLs, Falls, Fatigue level. 14
OVERALL PHYSICAL ACTIVITY Outcome # studies | N SMD (95% CI) p value GRADE rating MODERATE Mobility 19 | 1724 Medium; 0.60 (0.37, 0.83) <0.0001 downgraded for risk of bias MODERATE ADLs 9 | 910 Medium; 0.50 (0.15, 0.84) 0.005 downgraded for risk of bias MODERATE Cognitive Function 5 | 377 Small; 0.35 (0.09, 0.61) 0.008 downgraded for risk of bias MODERATE Quality of Life 6 | 500 Medium; 0.60 (0.13, 1.07) 0.0115 downgraded for risk of bias MODERATE 4 | 244 Large; -1.29 (-2.22, -0.36) 0.0067 downgraded for risk of bias Frailty MODERATE 4 | 1538 RR 0.58 (0.36, 0.93) 0.02 downgraded for risk of bias VERY LOW Falls 7 | 724 RR 0.80 (0.51, 1.26) 0.34 downgraded for risk of bias, inconsistency, and imprecision LOW Fatigue Level 3 | 184 No effect; -0.27 (-0.65, 0.12) 0.18 downgraded for risk of bias and imprecision Bold denotes significance p<0.05; Italics for binary outcome ; N = total number of participants; SMD = standardized mean difference; CI = confidence interval; RR = risk ratio 15
AEROBIC PHYSICAL ACTIVITY Outcome # studies | N SMD (95% CI) p value GRADE rating LOW Mobility 1 | 36 Medium; 0.71 (0.23, 1.20) 0.004 downgraded for risk of bias and imprecision VERY LOW ADLs 1 | 36 No effect; 0.46 (-0.03, 0.94) 0.06 downgraded for risk of bias and imprecision VERY LOW Cognitive Function 1 | 36 No effect; 0.15 (-0.50, 0.80) 0.65 downgraded for risk of bias and imprecision Quality of Life No data - Frailty No data - Falls No data - No effect; -0.39 (-0.87, VERY LOW Fatigue Level 1 | 36 0.11 0.09) downgraded for risk of bias and imprecision Hospital Services Use No data - Bold denotes significance p<0.05; N = total number of participants; SMD = standardized mean difference; CI = confidence interval 16
MOBILIZATION/REHAB PHYSICAL ACTIVITY Outcome # studies | N SMD (95% CI) p value GRADE rating MODERATE Mobility 3 | 330 Small; 0.29 (0.17, 0.42) <0.0001 downgraded for risk of bias MODERATE ADLs 1 | 182 Small; 0.48 (0.28, 0.67) <0.0001 downgraded for risk of bias LOW Cognitive Function 1 | 116 No effect; 0.12 (-0.10, 0.34) 0.28 downgraded for risk of bias and imprecision Quality of Life No data - Frailty No data - LOW Falls 1 | 184 RR 0.88 (0.69, 1.12) 0.30 downgraded for risk of bias and imprecision Fatigue Level No data - Hospital Services Use No data - Bold denotes significance p<0.05; Italics for binary outcome ; N = total number of participants; SMD = standardized mean difference; CI = confidence interval; RR = risk ratio 17
Recommend
More recommend
