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Aims: Frailty among cardiac rehabilitation (CR) participants is associated with worse health outcomes. However, no literature synthesis has quantified the relationship between frailty and CR outcomes. The purpose of this study was to examine frailty prevalence at CR admission, frailty changes during CR, and whether frailty is associated with adverse outcomes following CR., Methods and Results: We searched CINAHL, EMBASE, and MEDLINE for studies published from 2000 to 2023. Eligible studies included a validated frailty measure, published in English. Two reviewers independently screened articles and abstracted data. Outcome measures included admission frailty prevalence, frailty and physical function changes, and post-CR hospitalization and mortality. Observational and randomized trials were meta-analysed separately using inverse variance random-effects models. In total, 34 peer reviewed articles (26 observational, 8 randomized trials; 19 360 participants) were included. Admission frailty prevalence was 46% [95% CI 29-62%] and 40% [95% CI 28-52%] as measured by Frailty Index and Kihon Checklist (14 studies) and Frailty Phenotype (11 studies), respectively. Frailty improved following CR participation (standardized mean difference (SMD): 0.68, 95% CI 0.37-0.99; P < 0.0001; six studies). Meta-analysis of observational studies revealed higher admission frailty and increased participants' risk of all-cause mortality (hazard ratio: 9.24, 95% CI 2.93-29.16; P = 0.0001; four studies). Frailer participants at admission had worse physical health outcomes, but improved over the course of CR., Conclusion: High variability in frailty tools and CR designs was observed, and randomized controlled trial contributions were limited. The prevalence of frailty is high in CR and is associated with greater mortality risk; however, CR improves frailty and physical health outcomes., Registration: PROSPERO: CRD42022311765., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Cardiac rehabilitation (CR) is Class IA indication in patients after an acute cardiovascular (CV) event, with efficacy confirmed even in elderly or frail CV patients CV and geriatric outcomes. However, rate of referral and admission to CR of elderly CV patients remains very low. CV patients admitted in geriatric wards are often complex, multimorbid and frail. Therefore, the present position paper addressees their possible referral to CR, since many have various forms of CV diseases amenable to improve with CR. The multidisciplinary and comprehensive model of CR is applicable to these patients where evaluation and interventions should be tailored to the patient functional and clinical status, aiming to appropriate targets. Cardiologist, Geriatrician and other professionals, should synergistically integrate their competences, thus outlining also the new paradigm of "Cardiogeriatric Rehabilitation and Prevention", possibly leading to an increased awareness of the beneficial effect of CR and to an increased referral to CR from Geriatric departments. Operative recommendations are given, based on appropriateness and priority of indications, clinical risk and frailty level, integrating different expertise to reach more effective programs of care.

Objective: To investigate the effect of inspiratory muscle training (IMT) on cough strength in older people with frailty., Design: Single-blind randomized controlled trial., Setting: Day health care centers at 2 sites., Participants: Older people with frailty (N=60)., Interventions: Eligible people were randomly assigned to receive IMT program in addition to general exercise training (IMT group), or general exercise training alone (control group). The IMT group performed training using a threshold IMT device with the load set at 30% of maximum inspiratory mouth pressure in addition to the general exercise training program throughout the 8 weeks. The IMT took place twice a day and each session consisted of 30 breaths., Main Outcome Measures: Primary outcome was cough strength, measured as the cough peak flow (CPF), at the beginning and the end of the program., Results: Data from 52 participants (26 in each group) were available for the analysis. The mean age was 82.6 years; 33% were men. The change in CPF at the end of the program was 28.7±44.4 L/min in the IMT group and -7.4±26.6 L/min in the control group. A linear regression model showed that the presence or absence of IMT was associated with changes in CPF (mean difference between groups, 36.3; 95% confidence interval, 16.7-55.9; effect size, 0.99)., Conclusions: IMT may be a useful intervention to improve cough strength in frail older people., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Frailty is significantly correlated with a higher incidence of medical complications during hospitalization after esophagectomy. As frailty is thought to be a reversible condition, improving the reserve capacity through preoperative physical therapy is expected to reduce the risk of postoperative pulmonary complications (PPCs). Herein, we report our experience with preoperative physical therapy in a patient with esophageal cancer who was considered to have inadequate fitness for surgery owing to poor physical performance., Case Presentation: A 72-year-old man (height: 169.5 cm, weight: 54.7 kg, body mass index: 18.9 kg/m 2 ) with esophagogastric junction tumors (cStage IIIA) was hospitalized and scheduled to undergo surgery based on preoperative screening. He was categorized as frail according to the revised Japanese version of the Cardiovascular Health Study criteria and the Mini Nutritional Assessment Short-Form indicated severe malnutrition. We focused on physical therapy to improve exercise tolerance and prevent PPCs and devised a short-term intensive physical therapy program comprising minimal exercises that the patient could perform efficiently. The program consisted of only inspiratory muscle training and aerobic exercises. His maximal inspiratory pressure (MIP) and 6-min walking distance improved by 30 cm H 2 O and 145 m, respectively, on the day before surgery compared with those on day 8. The percentage predicted value of the MIP improved from 56.6% at the start of physical therapy to 102.9% on the day before surgery. On day 43, the patient underwent subtotal esophagectomy and was able to ambulate on postoperative day 5 without respiratory complications., Conclusion: We conducted a short-term, intensive, and minimal preoperative physical therapy program for a patient with esophageal cancer who had physical frailty. Preoperative physical therapy to increase the reserve capacity may result in a favorable postoperative course even in patients with physical frailty., (© 2024 The Author(s). Physiotherapy Research International published by John Wiley & Sons Ltd.)

Background: Sarcopenia and frailty often worsen in older adults because of declines in activities of daily living and social connections that are associated with chronic diseases and traumatic injuries such as falls and fractures. Exercise intervention for sarcopenia can take >3 months to improve muscle mass, muscle strength, and walking speed. Thus, a specialized intervention system for shorter periods of time is needed. In this study, we aimed to evaluate the short-term efficacy of an exercise program using the wearable cyborg Hybrid Assistive Limb (HAL) lumbar type in physical function in mobility-limited older adults who do not require transition to long-term care., Methods: This randomized, single-blind, parallel-group study involved 79 community-dwelling older adults with physical frailty or locomotive syndrome assigned to an intervention group (n = 40) with the HAL lumbar type exercise program or a control group (n = 39) without the exercise program. The intervention group underwent trunk training (including trunk and hip flexion, standing and sitting from a single sitting position, and squats) and gait training (treadmill and parallel bars) twice a week for 5 weeks while wearing the HAL lumbar type. The 10-m usual and maximum walking speeds, Timed Up and Go test results, 5-times chair-standing test results, 5-question Geriatric Locomotive Function Scale (GLFS-5) scores, body-fat percentage, and muscle mass were measured before and after the intervention and analyzed using the intention-to-treat method., Results: The intervention (23 % male; mean age, 74.7 ± 4.7 years) and control (21 % male; mean age, 75.1 ± 4.1 years) groups did not differ significantly in baseline characteristics. Seventy-seven participants completed the program; two withdrew for personal reasons. The mean difference (standard error) between the groups for the primary outcome (usual walking speed) was 0.35 (0.04) m/s; the time-by-group interaction was significant (p < 0.001). Secondary outcomes (maximum walking speed, Timed Up and Go test results, 5-times chair-standing test results, and GLFS-5 scores) significantly improved in the intervention group. Body composition was unchanged in both groups., Conclusions: A 5-week exercise program using the HAL lumbar type is a promising option for community-dwelling older adults with limited mobility who do not require nursing care, resulting in clinically meaningful improvements in most physical functions within a short period., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the prevalence and co-occurrence of common geriatric syndromes in geriatric rehabilitation inpatients., Design: Restoring Health of Acutely Unwell Adults (RESORT) and Enhancing Muscle Power in Geriatric Rehabilitation (EMPOWER-GR) are observational, longitudinal cohorts., Setting: Geriatric rehabilitation., Participants: Geriatric rehabilitation inpatients (N=1890 and N=200)., Interventions: Not applicable., Main Outcome Measures: Geriatric syndromes included polypharmacy, multimorbidity (Cumulative Illness Rating Scale), cognitive impairment, depression (Hospital Anxiety and Depression Scale/Geriatric Depression Scale), malnutrition (Global Leadership Initiative on Malnutrition), functional limitation (Katz index), falls, physical frailty (Fried), and sarcopenia (European Working Group on Sarcopenia in Older People 2)., Results: Inpatients in RESORT (R) (N=1890, 56% females) had a median age of 83.4 years (interquartile range [IQR], 77.6-88.4) and in EMPOWER-GR (E) (N=200, 57% females) of 79.8 years (IQR, 75.0-85.9). Polypharmacy (R, 82.2%; E, 84.0%), multimorbidity (R, 90.4%; E, 85.5%), functional limitation (R, 96.0%; E, 76.5%), and frailty (R, 91.8%; E, 92.2%) were most prevalent. Most inpatients had ≥5 geriatric syndromes at admission in both cohorts (R, 70.0%; E, 72.4%); few inpatients had only 1 (R, 0.4%; E, 1.5%) or no geriatric syndrome (R, 0.2%; E, 0.0%). Geriatric syndromes did not occur in isolation (without other syndromes), except for multimorbidity (R, 1%; E, 5%), functional limitation (R, 3%; E, 2%), falls (R, 0%; E, 4%), and frailty (R, 2%; E, 5%), which occurred in isolation in some inpatients; sarcopenia did not., Conclusions: Geriatric syndromes are highly prevalent at admission to geriatric rehabilitation, with a median of 5 co-occurring syndromes. Implications for diagnosis and intervention potential should be further addressed., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Understanding the patient perspective of frailty is critical to offering holistic patient-centred care. Rehabilitation strategies for patients with advanced chronic kidney disease (CKD) and frailty are limited in their ability to overcome patient-perceived barriers to participation, resulting in high rates of drop-out and non-adherence. The aim of this study was to explore patient perspectives and preferences regarding experiences with rehabilitation to inform a CKD/Frailty rehabilitation model., Methods: This qualitative study involved two focus groups, six individual semi-structured interviews and three caregiver semi-structured interviews with lived experience of advanced kidney disease and frailty. Interviews were recorded, transcribed, and coded for meaningful concepts and analysed using inductive thematic analysis using constant comparative method of data analysis employing Social Cognitive Theory., Results: Six major themes emerged including accommodating frailty is an act of resilience, exercise is endorsed for rehabilitation but existing programs have failed to meet end-users' needs. Rehabilitation goals were framed around return to normative behaviours and rehabilitation should have a social dimension, offering understanding for "people like us". Participants reported on barriers and disruptors to frailty rehabilitation in the CKD context. Participants valued peer-to-peer education, the camaraderie of socialisation and the benefit of feedback for maintaining motivation. Patients undertaking dialysis described the commodity of time and the burden of unresolved symptoms as barriers to participation. Participants reported difficulty envisioning strategies for frailty rehabilitation, maintaining a focus on the immediate and avoidance of future uncertainty., Conclusions: Frailty rehabilitation efforts in CKD should leverage shared experiences, address comorbidity and symptom burden and focus on goals with normative value., (© 2024. Crown.)

Continuing rehabilitation after hip fractures is recommended to improve physical function and quality of life. However, the long-term implementation status of postoperative rehabilitation is unclear. This study aims to investigate the implementation status of postoperative rehabilitation for older patients with hip fractures and the factors associated with continuing rehabilitation. A retrospective cohort study evaluated medical and long-term care insurance claims data of patients aged 75 years or older in Kyoto City, Japan, who underwent hip fracture surgeries from April 2013 to October 2018. We used logistic regression analysis to examine factors associated with six-month rehabilitation continuation. Of the 8,108 participants, 8,037 (99%) underwent rehabilitation the first month after surgery, but only 1,755 (22%) continued for six months. The following variables were positively associated with continuing rehabilitation for six months: males (adjusted odds ratio: 1.41 [95% confidence interval: 1.23-1.62]), an intermediate frailty risk (1.50 [1.24-1.82]), high frailty risk (2.09 [1.69-2.58]) estimated using the hospital frailty risk scores, and preoperative care dependency levels: support level 1 (1.69 [1.28-2.23]), support level 2 (2.34 [1.88-2.90]), care-need level 1 (2.04 [1.68-2.49]), care-need level 2 (2.42 [2.04-2.89]), care-need level 3 (1.45 [1.19-1.76]), care-need level 4 (1.40 [1.12-1.75]), and care-need level 5 (1.31 [0.93-1.85]). In contrast, dementia was cited as a disincentive (0.53 [0.45-0.59]). Less than 30% of older patients continued rehabilitation for six months after surgery. Factors associated with continuing rehabilitation were male sex, higher frailty risk, care dependency before hip fracture surgeries, and non-dementia., Competing Interests: We have read the journal’s policy, and the authors of this manuscript have the following competing interests to declare: This study was conducted as part of a project commissioned by Kyoto City, Japan. TN reported receiving grants from the operating expenses of the Department of Health Informatics, Graduate School of Public Health, Kyoto University [grant number 021515]; from the Cabinet Office, Government of Japan [grant number JPJ012425]; and a consignment fee from Kyoto City (FY 2020). YT and MT reported receiving grants from the Japan Society for the Promotion of Science during the study [grant numbers 20H01594 and 21K21166]. JM received honoraria for lectures from ASAHI KASEI PHARMA CORPORATION and UCB Japan Co. Ltd. outside this submitted work., (Copyright: © 2024 Sasaki et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement., Objectives: To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect., Review Design: Systematic review and network meta-analysis., Eligibility Criteria: Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention., Main Outcomes: Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year., Data Sources: We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists., Review Methods: Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis)., Results: We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive., Limitations: High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts., Conclusions: Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence., Future Work: Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further., Study Registration: This study is registered as PROSPERO CRD42019162195., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment ; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Purpose: This study examined the impact of frailty and prefrailty on mid-term outcomes and rehabilitation courses after cardiac surgery., Methods: A total of 261 patients (median age: 73 years; 30% female) who underwent elective cardiac surgery were enrolled in this study. The Japanese version of the Cardiovascular Health Study Frailty Index classified 86, 131, and 44 patients into frailty, prefrailty, and robust groups, respectively. We examined the recovery of walking ability, outcomes at discharge, mid-term all-cause mortality, and rehospitalization related to major adverse cardiovascular and cerebrovascular events (MACCE) across the three cohorts., Results: The 3-year survival rates in the frailty, prefrailty, and robust groups were 87%, 97%, and 100%, respectively (p = 0.003). The free event rates of all-cause mortality and re-hospitalization related to MACCE were 59%, 79%, and 95%, respectively (p < 0.001), with a graded elevation in adjusted morbidity among patients in the prefrailty (hazard ratio [HR], 4.57; 95% confidence interval [CI], 1.08-19.4) and frailty (HR, 9.29; 95% CI 2.21-39.1) groups. Patients with frailty also experienced a delayed recovery of walking ability and a reduced number of patients with frailty were discharged home., Conclusion: Frailty and prefrailty adversely affect the mid-term prognosis and rehabilitation course after cardiac surgery., (© 2024. The Author(s).)

Objective: To identify the effect of exercise interventions on physical frailty in community-dwelling older adults., Methods: Relevant articles were searched in MEDLINE, LILACS, Scielo, Embase, and PEDro in November 2022, based on a protocol registered in PROSPERO and according to items prescribed in Report for Systematic Reviews and Meta-Analyses, using Health Sciences Descriptors (DeCS) and free terms for search strategy, with no language restrictions. The studies were considered if they had been published between January 2010 and November 2022, and were randomized clinical trials in which pre-frail and frail older community-dwelling adults had undergone exercise-based physical therapy., Results: The systematic review found 5360 citations; after screening, abstract, and full-text screening for eligibility, seven studies were included, involving 1304 participants overall. The exercise modalities differed substantially between studies. The meta-analysis identified a statistically significant difference in frailty between older adults who exercised compared with those who exercised with no or minimal intervention. No heterogeneity between articles was observed, and the risk of bias was considered low according to funnel plot visual inspection., Conclusions: The results of this review suggest that physical therapy programs are effective in decreasing levels of physical frailty in community-dwelling older adults., (© 2024 John Wiley & Sons Ltd.)

Background: Frailty correlates with poor clinical outcomes and is not routinely assessed in neurorehabilitation inpatient settings., Methods: We recruited adults from two neurorehabilitation units. We administered six validated tools for assessing frailty and collected data around length of stay, discharge, readmission and change in rehabilitation outcome measures., Results: Seventy-eight participants aged between 31 and 84 years were recruited with a range of neurological diagnoses. Frailty prevalence ranged between 23% and 46%, depending on the scale used, with little agreement between tools. Frailty status did not correlate with age, gender, length of stay, discharge destination and rehabilitation outcome measures. One-year readmission was higher in participants rated as frail by the Frail-Non-Disabled Questionnaire, the FRESH-screening questionnaire and the Clinical Frailty Scale., Conclusion: Frailty ascertainment was variable depending on the tool used. Three frailty indices predicted readmission rate at 1 year but no other outcome measures. Therefore, frailty tools may have limited utility in this clinical population., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The effectiveness of isolated resistance training (RT) on cognitive function among older adults with schizophrenia is insufficiently investigated. This study investigated the effectiveness of 12-weeks POWER rehabilitation, a novel RT regimen, on cognitive function among older patients with schizophrenia and frailty., Methods: Thirty-two older adults with schizophrenia and frailty were enrolled and randomized to receive either a 12-week, twice weekly POWER rehabilitation, or without add-on training. Cognitive functioning was assessed using mini-mental state examination (MMSE), digit symbol substitution test, color trail task (CTT), and digit span task (DST). Physical performance was assessed by walking speed and hand grip strength. The generalized estimating equations was used to compare pre- and post-training outcome measure between groups., Results: Between-group analysis revealed significant improvement in CTT1 and hand grip strength in the intervention group compared to the controls. Subgroup analyses showed CTT1 performance significantly improved after 12 weeks of POWER rehabilitation in the intervention group (time, p < .001), independent of age, educational level, global cognition, depressive symptoms, and psychotropic medication use. Increased hand grip strength was significantly associated with improved performance in MMSE, CTT1, and DST forward at study endpoint., Conclusion: A 12-week POWER rehabilitation for older patients with schizophrenia and frailty is safe and feasible, and may benefit physical and some domains of cognitive functioning., (© 2024 John Wiley & Sons Australia, Ltd.)

Introduction: Aging is associated with an increased burden of multi-morbidity and disease related functional loss and disability, widely impacting patients and health care systems. Frailty is a major actor in age-related disability and is an important target for rehabilitation interventions, considering that is a reversible condition., Evidence Acquisition: A working group of members of the ISPRM, responding to WHO 2030 call for action to strengthen rehabilitation, was established to assess the quality and implementability of the existing guidelines for the rehabilitation of frailty. Guidelines were retrieved using a systematic search on Pubmed, Scopus and Web of Science and from the reference lists of screened articles. The included guidelines were evaluated using the AGREE II to assess their quality and using the AGREE-REX to assess their clinical credibility and implementability. Guidelines with a score >4 in the AGREE II item evaluating the overall quality of the guideline were considered for endorsement. Finally, nine external reviewers evaluated the applicability of each recommendation from the endorsed guidelines, providing comments about the barriers and facilitators for their implementation in their country., Evidence Synthesis: Ten guidelines were retrieved and evaluated by the working group, of which four guidelines, i.e. the WHO Guidelines on Integrated Care for Older People, the FOCUS guidelines, the Asia-Pacific Clinical Practice Guidelines for the Management of Frailty and the ICFSR International Clinical Practice Guidelines for Identification and Management of Frailty, were considered for endorsement. All these guidelines were rated as of adequate quality and implementability., Conclusions: The WHO Guidelines on Integrated Care for Older people (24) the ICFSR International Clinical Practice Guidelines for Identification and management of Frailty (15), the FOCUS guidelines (25) and the Asia Pacific Clinical Practice Guidelines (14) for the Management of Frailty have the best quality and applicability of the existing guidelines on the management of frailty, we suggest that should be employed to define the standards of care for patients with frailty. There are barriers for their implementation, as stated by our experts, to take into account, and some of them are country- or region-specific. Screening for frailty, exercise, nutrition, pharmacological management, social and psychological support, management of incontinence, and an overall comprehensive clinical management are the best tools to face upon frailty.

Background: After an acute infection, older persons may benefit from geriatric rehabilitation (GR)., Objectives: This study describes the recovery trajectories of post-COVID-19 patients undergoing GR and explores whether frailty is associated with recovery., Design: Multicentre prospective cohort study., Setting: 59 GR facilities in 10 European countries., Participants: Post-COVID-19 patients admitted to GR between October 2020 and October 2021., Methods: Patients' characteristics, daily functioning (Barthel index; BI), quality of life (QoL; EQ-5D-5L) and frailty (Clinical Frailty Scale; CFS) were collected at admission, discharge, 6 weeks and 6 months after discharge. We used linear mixed models to examine the trajectories of daily functioning and QoL., Results: 723 participants were included with a mean age of 75 (SD: 9.91) years. Most participants were pre-frail to frail (median [interquartile range] CFS 6.0 [5.0-7.0]) at admission. After admission, the BI first steeply increased from 11.31 with 2.51 (SE 0.15, P < 0.001) points per month and stabilised around 17.0 (quadratic slope: -0.26, SE 0.02, P < 0.001). Similarly, EQ-5D-5L first steeply increased from 0.569 with 0.126 points per month (SE 0.008, P < 0.001) and stabilised around 0.8 (quadratic slope: -0.014, SE 0.001, P < 0.001). Functional recovery rates were independent of frailty level at admission. QoL was lower at admission for frailer participants, but increased faster, stabilising at almost equal QoL values for frail, pre-frail and fit patients., Conclusions: Post-COVID-19 patients admitted to GR showed substantial recovery in daily functioning and QoL. Frailty at GR admission was not associated with recovery and should not be a reason to exclude patients from GR., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Background: With the significant increase in the number of long-lived elderly people living at home, the development of effective physical exercise interventions at home becomes essential to preserve their independence and delay institutionalization and hospitalizations., Objective: to map and describe home exercise programs for elderly people aged 80 or over with physical frailty., Methods: The scoping review allowed the inclusion of several methodologies and varied perspectives, maintaining rigor in accordance with the methodological steps of the Joanna Briggs Institute (JBI). The systematic search covered studies available until May 2023 in five databases and gray literature. Frailty was assessed according to the criteria of Fried et al. (2001), physical performance scale (SPPB), such as gait and mobility, and the authors' assessment of reduced physical function were considered. The study followed the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines and is publicly available in the Open Science Framework (OSF) repository., Results: Twenty studies were identified that met the inclusion criteria. The total number of elderly people investigated in the study was 1,796. The most important physical interventions were muscular strength training, mainly of the lower limbs, together with flexibility, balance, aerobic and functional training. These home interventions have demonstrated potential, safety and effectiveness in preventing and alleviating physical frailty. These home interventions demonstrated potential, safety and effectiveness in preventing and alleviating physical frailty, adherence in most studies varied between 72% and 89%., Conclusion: This study will allow us to design home-based exercise interventions, potentially providing practical solutions and assisting healthcare professionals in home-based interventions to reduce and mitigate physical frailty in the growing population of older adults. It will also help fill the existing knowledge gap and provide recommendations for future research., Competing Interests: The authors have no conflict of interests in relation to this scientific article.

More than half of older adults are frail or prefrail in the United States, and hospital-associated deconditioning likely increases this risk. However, the impact of frailty on potential functional improvements after hospital discharge is poorly understood. We sought to identify the influence of baseline frailty on gait speed change in older adults receiving home health physical therapy (PT) after hospital discharge. The severity of frailty was assessed using Cardiovascular Health Study frailty criteria (weakness, slowness, weight loss, physical inactivity, and exhaustion). Gait speed was measured at baseline and 60-days post-hospital discharge. Upon admission to home health rehabilitation services, half of older adults (total N=250) were considered frail, with slowness (90%) and weakness (75%) being the most common characteristics. Older adults, whether pre-frail or frail, demonstrated similar and clinically meaningful improvements in gait speed after receiving home health rehabilitation for 60 days following hospital discharge. These results suggest that clinicians caring for older adults in the hospital can counsel both pre-frail and frail patients that, with home health rehabilitation, clinically significant improvements in function can be expected over the 2 months following discharge. Furthermore, we observed encouraging gait speed improvement with physical therapy following hospitalization in older adults. Results can inform anticipatory guidance on hospital discharge., Competing Interests: R.E. Burke is an Advisory Board Member, Mighty Health.

Older patients face increasing challenges in preserving mobility during hospitalization. This retrospective cohort study aimed to evaluate the effect of an Occupational Therapy (OT) program on mobility at discharge in older patients admitted to an Acute Geriatric Unit (AGU). All patients aged ≥65 years consecutively admitted to the AGU in an 18-month period were included in the study if scoring <4 or ≥ 8 at the Clinical Frailty Scale. Overall, 807 patients (median age 85 years, 50.2% females) were included: 665 (82%) received OT, while 142 who did not receive OT were used as controls. The Cumulated Ambulation Scale (CAS) was used to assess mobility at discharge. By multivariable logistic regression, OT was independently associated with higher odds of achieving higher CAS score at discharge. These findings emphasize the potential benefits of OT in acute geriatric settings, providing valuable insights for preserving mobility of frail older individuals during hospitalization., Competing Interests: All authors declare no competing interests.

Introduction: Concurrent training has been shown to be a beneficial approach to improve overall health status in older adults. However, little is known about the adaptations of this type of training in the long term (i.e., after cessation of exercise), even less in older people affected by frailty syndrome. Therefore, this study aimed (i) to assess the effects of a 6-week concurrent training program composed of power-oriented resistance training and fast walking interval training on physical function, muscle power, disability in activities of daily living and frailty in pre-frail and frail older people, and (ii) to assess the effects of a 6-month detraining period on these outcomes., Methods: A total of 59 pre-frail and frail older adults (&gt;75 years old; Frailty Phenotype &gt;1) were allocated into intervention (INT; n = 32; 81.8 years; 21 women) or control (CON; n = 27; 82.5 years; 19 women) groups. Primary outcomes of this study were Short Physical Performance Battery (SPPB), relative sit-to-stand (STS) power, Barthel index, Lawton scale and Frailty Phenotype. Assessments were performed at baseline (PRE), after the concurrent training programme (POST) and after 6 months of follow-up (DET) in both groups. Mixed model repeated measures ANOVA with Bonferroni's post hoc tests was used., Results: Immediately after the intervention (∆ = POST-PRE), INT improved SPPB (∆ = 3.0 points; p &lt; 0.001), relative STS power (∆ = 0.87 W·kg-1; p &lt; 0.001) and reduced their frailty levels (∆ = -1.42 criteria; p &lt; 0.001), while no changes were observed in CON. After 6 months of detraining (∆ = DET-PRE), INT showed higher SPPB (∆ = 2.2 points; p &lt; 0.001), higher relative STS power (∆ = 0.73 W·kg-1; p &lt; 0.001) and lower frailty (∆ = -1.24 criteria; p &lt; 0.001) values than those reported at baseline, which were significantly different than those reported by CON. Both, Barthel index and Lawton scale values were not modified during the study in either group., Conclusions: The 6-week concurrent training program improved physical function, muscle power and reduced frailty in pre-frail and frail older people and these improvements were maintained above baseline levels after 6 months of detraining. However, due to the individual variability found, future studies of long-term responders versus non-responders in frail populations are required., (© 2024 S. Karger AG, Basel.)

Introduction: Kidney transplant candidates (KTCs) need to be in optimal physical and psychological condition prior to surgery. However, KTCs often experience compromised functional capacity which can be characterised as frailty. Prehabilitation, the enhancement of a person's functional capacity, may be an effective intervention to improve the health status of KTCs. The PREhabilitation of CAndidates for REnal Transplantation (PreCareTx) study aims to examine the effectiveness of a multimodal prehabilitation programme on the health status of KTCs, and to explore the potential of implementation of prehabilitation in daily clinical practice., Methods and Analysis: This study uses a single centre, effectiveness-implementation hybrid type I study design, comprised of a randomised controlled trial and a mixed-methods study. Adult patients who are currently on the transplant waiting list or are waitlisted during the study period, at a university medical centre in The Netherlands, will be randomly assigned to either prehabilitation (n=64) or care as usual (n=64) groups. The prehabilitation group will undergo a 12-week home-based, tailored prehabilitation programme consisting of physical and/or nutritional and/or psychosocial interventions depending on the participant's deficits. This programme will be followed by a 12-week maintenance programme in order to enhance the incorporation of the interventions into daily life. The primary endpoint of this study is a change in frailty status as a proxy for health status. Secondary endpoints include changes in physical fitness, nutritional status, psychological well-being, quality of life and clinical outcomes. Tertiary endpoints include the safety, feasibility and acceptability of the prehabilitation programme, and the barriers and facilitators for further implementation., Ethics and Dissemination: Medical ethical approval was granted by the Medical Ethics Committee Groningen, Netherlands (M22.421). Written informed consent will be obtained from all participants. The results will be disseminated at international conferences and in peer-reviewed journals., Trial Registration Number: ClinicalTrials.gov, NCT05489432., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Despite the high burden of frailty among cardiac rehabilitation (CR) participants, it is unclear which frailty-related deficits are related to program completion., Methods: Data from a single-centre exercise- and education-based CR program were included. A frailty index (FI) based on 25 health deficits was constructed. Logistic regression was used to estimate the odds of CR completion based on the presence of individual FI items. The odds of completion for cumulative deficits related to biomarkers, body composition, quality of life, as well as a composite of traditional and non-traditional cardiovascular risk factor domains were examined., Results: A total of 3,756 individuals were included in analyses. Eight of 25 FI variables were positively associated with program completion while 8 others were negatively associated with completion. The variable with the strongest positive association was the food frequency questionnaire score (OR 1.27 (95% CI 1.14, 1.41), whereas the deficit with strongest negative association was a decline in health over the last year (OR 0.74 (95% CI 0.58, 0.93). An increased number of cardiovascular deficits were associated with an increased odds of CR completion (OR per 1 deficit increase 1.16 (95% CI 1.11, 1.22)). A higher number of traditional CR deficits were predictive of CR completion (OR 1.22 (95% CI 1.16, 1.29)), but non-traditional measures predicted non-completion (OR 0.95 (95% CI 0.92, 0.97))., Conclusion: A greater number of non-traditional cardiovascular deficits was associated with non-completion. These data should be used to implement intervention to patients who are most vulnerable to drop out to maximize retention., (© 2023. The Author(s).)

Introduction: Prehabilitation prior to surgery has been shown to reduce postoperative complications, reduce length of hospital stay and improve quality of life after cancer and limb reconstruction surgery. However, there are minimal data on the impact of prehabilitation in patients undergoing cardiac surgery, despite the fact these patients are generally older and have more comorbidities and frailty. This trial will assess the feasibility and impact of a prehabilitation intervention consisting of exercise and inspiratory muscle training on preoperative functional exercise capacity in adult patients awaiting elective cardiac surgery, and determine any impact on clinical outcomes after surgery., Methods and Analysis: PrEPS is a randomised controlled single-centre trial recruiting 180 participants undergoing elective cardiac surgery. Participants will be randomised in a 1:1 ratio to standard presurgical care or standard care plus a prehabilitation intervention. The primary outcome will be change in functional exercise capacity measured as change in the 6 min walk test distance from baseline. Secondary outcomes will evaluate the impact of prehabilitation on preoperative and postoperative outcomes including; respiratory function, health-related quality of life, anxiety and depression, frailty, and postoperative complications and resource use. This trial will evaluate if a prehabilitation intervention can improve preoperative physical function, inspiratory muscle function, frailty and quality of life prior to surgery in elective patients awaiting cardiac surgery, and impact postoperative outcomes., Ethics and Dissemination: A favourable opinion was given by the Sheffield Research Ethics Committee in 2019. Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer-reviewed publication., Trial Registration Number: ISRCTN13860094., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Frailty is a strong predictor of adverse postoperative outcomes. Prehabilitation may improve outcomes after surgery for older people with frailty by addressing physical and physiologic deficits. The objective of this trial is to evaluate the efficacy of home-based multimodal prehabilitation in decreasing patient-reported disability and postoperative complications in older people with frailty having major surgery., Methods and Analysis: We will conduct a multicentre, randomised controlled trial of home-based prehabilitation versus standard care among consenting patients >60 years with frailty (Clinical Frailty Scale > 4) having elective inpatient major non-cardiac, non-neurologic or non-orthopaedic surgery. Patients will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of > 3 weeks of prehabilitation (exercise (strength, aerobic and stretching) and nutrition (advice and protein supplementation)). The study has two primary outcomes: in-hospital complications and patient-reported disability 30 days after surgery. Secondary outcomes include survival, lower limb function, quality of life and resource utilisation. A sample size of 750 participants (375 per arm) provides >90% power to detect a minimally important absolute difference of 8 on the 100-point patient-reported disability scale and a 25% relative risk reduction in complications, using a two-sided alpha value of 0.025 to account for the two primary outcomes. Analyses will follow intention to treat principles for all randomised participants. All participants will be followed to either death or up to 1 year., Ethics and Dissemination: Ethical approval has been granted by Clinical Trials Ontario (Project ID: 1785) and our ethics review board (Protocol Approval #20190409-01T). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media., Trial Registration Number: NCT04221295., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Frailty, a physiological syndrome (FS) affecting primarily the older adults, manifests itself through significantly depleted bodily reserves, and appreciably higher (up to over threefold) individual exposure to fall risk. Concomitant medical conditions such as balance impairment, reduced visual acuity, limited mobility, and significantly diminished daily functional performance further exacerbate the patients' condition. Their resultant susceptibility to frequent hospitalisations makes their prognosis even worse. This narrative review aimed to provide an overview of published studies focused on rehabilitation management approaches aided by virtual reality (VR) technology in frail older adults. The authors had it also augmented with their own, evidence-based body of experience in rehabilitation. Making use of technologically advanced exercise machinery, specially adapted for rehabilitating frail older adults, combined with a structured exercise regimen, further aided by the application of select virtual reality (VR) technology solutions, clearly proved effective. Consequently, the patients were helped to move back from the frail to the pre-frail stage, as well as had their motor and cognitive functions appreciably enhanced. The application of modern technology in rehabilitating older adults over 65, affected by FS, when specifically aided by the select VR technology solutions, was also proven to complement successfully the conventional rehabilitation management. The overall versatility of the VR technology solutions, e.g., adaptation for home use allowing remote supervision, also makes this novel approach to rehabilitation far more appealing to the patients. They find it both very attractive and far more mentally engaging. Its considerable potential lies mostly in being appreciably more effective in bringing in desirable therapeutic outcomes.

Objectives: To investigate the effects of a 12-month home-based exercise program on functioning and falls among persons with signs of frailty., Design: A randomized controlled trial with a 1:1 allocation., Setting: Home-based., Participants: Home-dwelling persons aged 65 years or older meeting at least 1 frailty phenotype criteria (N=300). The mean age of the participants was 82.2±6.3 years, 75% were women, 61% met 1-2 frailty criteria, and 39% met ≥3 criteria., Interventions: A 12-month, individually tailored, progressive, and physiotherapist-supervised physical exercise twice a week (n=150) vs usual care (n=149)., Main Outcome Measures: FIM, Short Physical Performance Battery (SPPB), handgrip strength, instrumental activities of daily living (IADL), and self-reported falls and physical activity (other than intervention). Assessed 4 times at home over 12 months., Results: FIM deteriorated in both groups over 12 months, -4.1 points (95% confidence interval [CI], -5.6 to -2.5) in the exercise group and -6.9 (95% CI, -8.4 to -2.3) in the usual care group (group P=.014, time P<.001, interaction P=.56). The mean improvement in SPPB was significantly greater in the exercise group (1.6 [95% CI, 1.3-2.0]) than in the usual care group (0.01 [95% CI, -0.3 to 0.3]) (group P<.001, time P=.11, interaction P=.027). The exercise group reported significantly fewer falls per person-year than the usual care group (incidence rate ratio, 0.47 [95% CI, 0.40-0.55]; P<.001). There was no significant difference between the groups over 12 months in terms of handgrip strength, IADL function, or self-reported physical activity., Conclusions: One year of physical exercise improved physical performance and decreased the number of falls among people with signs of frailty. FIM differed between the groups at 12 months, but exercise did not prevent deterioration of FIM, IADL, or handgrip strength., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Patients with chronic intractable dizziness (henceforth referred to as "intractable dizziness") have a high risk of developing frailty complications. This warrants investigation of a combined treatment for intractable dizziness and frailty. Ninjin'yoeito (NYT), a traditional Japanese medicine (Kampo medicine), is reportedly effective in treating frailty and sarcopenia. Herein, we report on the results of a retrospective study that involved the combined application of NYT and dizziness rehabilitation therapy (henceforth referred to as "dizziness rehabilitation"). Of the 31 patients with intractable dizziness, 14 developed frailty, indicating a complication rate of 45.2%. This in turn was approximately 4 times higher than the previously reported rates. Eleven patients became non-frail after 6 months of the combined treatment, and their improvement rate was 78.6%. The aforementioned combination therapy not only improved dizziness but also improved frailty. Following 6 months of combined treatment, patients in the frailty group exhibited improvement in the Dizziness Handicap Inventory score, frailty symptoms, Kihon checklist score, and visual analog scale score (fatigue), and approached the pre-treatment values of those in the non-frailty group. Together, our results highlight the need to combine the treatment for intractable dizziness and frailty., (Copyright © 2021. Published by Elsevier Ltd.)

Introduction: Frailty is a predictor of morbidity and mortality in cirrhosis. Although evidence for prehabilitation is promising, the data for liver transplant (LT) candidates are limited. The primary aim of this study was to evaluate the effect of a novel prehabilitation strategy on changes in frailty metrics and survival in LT candidates. The secondary aim was to determine liver-related and extrahepatic conditions associated with frailty., Methods: In this ambispective cohort study, all patients underwent frailty assessment using the liver frailty index (LFI), 6-minute walk test, and gait speed test performed by a dedicated physical therapist. Home-based exercise prescription was individualized to each patient's baseline physical fitness., Results: We included 517 patients (59% men, median age 61 years, and a model for end-stage liver disease score of 12) evaluated during 936 PT visits. Frailty metrics were affected by age, sex, and liver-related parameters, but not by model for end-stage liver disease. Patients with nonalcoholic fatty liver disease and alcohol-related cirrhosis had worse frailty metrics by all tools. We demonstrated the feasibility of prehabilitation in improving both LFI and 6-minute walk test, particularly in adherent patients. A median LFI improvement of 0.3 in frail patients was associated with improved survival in univariate analysis. Compliance with physical therapist visits (hazards ratio = 0.35 [0.18-0.67] for 2 visits and hazards ratio = 0.54 [0.31-0.94] for ≥3 visits) was independently associated with increased survival., Discussion: Prehabilitation improves frailty metrics in LT candidates and is associated with a survival advantage. Our findings provide a framework for the standardized prehabilitation program in LT candidates while prioritizing compliance, adherence, and on-training LFI goal accomplishment., (Copyright © 2021 by The American College of Gastroenterology.)

Wearable devices provide real-time and patient-powered data that enable the development of personalized health promotion and management programs. This study aimed to explore the clinical benefits of using the wearable device and to examine associated factors, utilization patterns on health status. 319 community-living adults aged 50-85 years were enrolled and clinically followed for 12 months. Participants were categorized into 3 groups based on the wearable device utilization patterns (active: >30 days of use, non-active: <3 days of use, usual: 3-30 days of use). 128 (40.1%) and 98(30.7%) were active and usual wearable device users, and no significant differences in the baseline demographic characteristics and functional status were noted across groups. Higher cognitive performance was significantly associated with the wearable device use (OR: 1.3,95%CI: 1.1-1.5, p=0.005). Multivariable linear regression showed that 0.16 m/s increase in walking speed among active users, which was significantly higher than non-active users (p=0.034). Compared to usual users, active users had higher average daily, weekday, and holiday step counts. The walking speed increased for 0.03 m/s when participants walked 1,000 more daily step counts (p=0.020). Active use of wearable devices substantially increased walking speed, which suggested better functional outcomes and survival benefits in the future.

Frailty is a highly prevalent multisystem syndrome in older adults with heart failure (HF) and is associated with poor clinical prognosis and increased complexity of care. While frailty is neither disease nor age specific, it is a clinical manifestation of aging-related processes that reflects a reduced physiological ability to tolerate and recover from stress associated with aging, disease, or therapy. Within this context, physical frailty, which is distinctly oriented to physical functional domains (e.g., muscle weakness, slowness, and low activity), has been recognized as a critical vital sign in older persons with HF. Identification and routine assessment of physical frailty, using objective physical performance measures, may guide the course of patient-centered treatment plans that maximize the likelihood of improving clinical outcomes in older HF patients. Exercise-based rehabilitation is a primary therapy to improve cardiovascular health in patients with HF; however, the limited evidence supporting the effectiveness of exercise tailored to older and frail HF patients underscores the current gaps in management of their care. Interdisciplinary exercise interventions designed with consideration of physical frailty as a therapeutic target may be an important strategy to counteract functional deficits characteristic of frailty and HF, and to improve patient-centered outcomes in this population. The purpose of this current review is to provide a better understanding of physical frailty and its relation to management of care in older patients with HF. Implications of movement-based interventions, including exercise and physical rehabilitation, to prevent or reverse physical frailty and improve clinical outcomes will further be discussed., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Frailty is a state of age-related reduced physiological reserve characterized by an increased risk of adverse clinical outcomes. Studies have shown that exercise can improve frailty in older people. However, it remains to be seen which exercises will most improve the fitness of older people with frailty or those at the risk for frailty.Objective: This protocol aims to determine whether physical exercise can improve frailty in older people, and if which methods are most effective., Methods: We searched the following databases for relevant articles published between January 1, 2012 and January 1, 2021: PubMed, EMBASE, the Cochrane Library, Wanfang, the China National Knowledge Infrastructure, Clinical Trials Database, and the Science Network. Two independent reviewers will carry out data extraction, discuss and resolve differences, and obtain consensus from the third author. We will select randomized control trials (RCTs) according to the preformulated inclusion criteria. The main outcomes in this study are scores from Fried Frailty Phenotype Criteria; the Frailty Trait Scale-short form; the SHARE Frailty Instrument; the FRAIL scale; the Gérontopôle Frailty Screening Tool; the Clinical Frailty Scale, the Rockwood and Mitnitsky Frailty Index; the Study of Osteoporotic Fractures Index; the Edmonton Frailty Scale; the Fatigue, Resistance, Ambulation, Illness and Loss of Weight Index; the Multidimensional Prognostic Index; the Tilburg Frailty Indicator; PRISMA-7; the Groningen Frailty Indicator; the Sherbrooke Postal Questionnaire; and the Kihon Checklist. Secondary outcomes are muscle strength, gait velocity, stair-climbing power, and level of spontaneous physical activity. If the heterogeneity test shows slight or no statistical heterogeneity, a fixed effects model will be used for data synthesis; otherwise, a random effects model will be used. We will develop a unified data extraction table that includes a number of parameters. The Cochrane Cooperative Bias Risk Tool will be used to evaluate the methodological quality of the selected RCTs. RevMan Manager 5.3 and STATA 14.0 will be used for data analysis if enough RCTs (more than 10) are identified and selected., Result: The final results will provide information on the effectiveness of intervention programs for frail older adul and further demonstrate which exercise programs are more effective and which methods can significantly improve frailty., Conclusion: This protocol will contribute to the development of more effective interventions for elderly individuals with frailty., Ethics and Dissemination: This study applies existing literature references; therefore, ethical approval is not required., Inplasy Registration Number: INPLASY202130107., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To describe how different key stakeholders (ie, interprofessional clinical care team and patients) perceive their role in promoting in-hospital mobility by systematically synthesizing qualitative literature., Data Sources: PubMed, Ovid MEDLINE, Ovid PsychInfo, and Cumulative Index to Nursing and Allied Health were searched using terms relevant to mobility, hospitalization, and qualitative research. A total of 510 unique articles were retrieved and screened for eligibility., Study Selection: Eligible qualitative studies included stakeholder perspectives on in-hospital mobility, including patients, nursing staff, rehabilitation staff, and physicians. Eleven articles remained after inclusion/exclusion criteria were applied., Data Extraction: At least 2 authors independently read, coded, and derived themes from each study. We used a team-based inductive approach to thematic synthesis informed by critical realism and the socioecological model. Reciprocal translation unified convergent and divergent constructs across primary studies. Investigator triangulation enhanced interpretation., Data Synthesis: Three primary themes emerged: (1) patient, family, and clinician expectations shape roles in in-hospital mobility; (2) stakeholders' role in mobility depends on hospital environment, infrastructure, culture, and resources; and (3) teamwork creates successful in-hospital mobility, but lack of coordination and cooperation leads to delay in mobilizing. Studies suggested that while mobility is an essential construct in the professional role of clinicians and in the personal identity of patients, the ability of stakeholders to realize their role in mobility is highly dependent on the hospital physical and cultural environment, administrative support, clarity in professional roles, and teamwork., Conclusions: Interventions designed to address the problem of low hospital mobility should take a systems approach and consider allocation of resources, clarity around professional responsibilities, and elevation of patient and clinician expectations surrounding mobility., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Prehabilitation encompasses multidisciplinary interventions to improve health and lessen incidence of surgical deterioration by reducing physiologic stress and functional decline. This study presents an interim analysis to demonstrate prehabilitation for hepatopancreatobiliary (HPB) surgical patients., Methods: In 2018, a structured prehabilitation pilot program was implemented. Eligibility required HPB malignancy, neoadjuvant chemotherapy, and residence within hour drive. Patients were enrolled into the 4-month program. The fitness component was composed of timed up and go test and grip strength with exercise recommendations. Nutrition involved evaluation of sarcopenic obesity, glucose management, and smoking and alcohol counseling. Psychological services included psychosocial assessments and advanced care planning, with social work referrals. Component were evaluated monthly by a physician using laboratory results, nutritional data and questionnaires, psychological assessments, and validated fitness tests. Nurse navigators spoke with patients weekly to monitor compliance., Results: At 12 months, nineteen patients were enrolled. Ten completed prehabilitation, neoadjuvant chemotherapy and underwent their surgical procedure. There were no differences found after prehabilitation in functional status, physical performance, psychosocial assessments, or nutrition. Frailty, as assessed by Fried frailty criteria, improved significantly after prehabilitation ( P < .0001). Symptom severity and laboratory values did not change. Length of stay was 6.5 days and all patients were discharged to home. There was 1 readmission for transient ischemic attack and 90-day mortality rate was 0%., Discussion: Prehabilitation to improve recovery is a promising concept encompassing a wide array of multidisciplinary assessments and interventions. It may demonstrate a protective effect on physiologic decline from chemotherapy and may reverse frailty phenotypes.

Frailty is an important medical syndrome that can be prevented or treated with specific interventions. However, there is limited research evidence on multifactorial perspectives of frailty management and its impact on daily function including mobility declines and changes in life-space mobility. Using the person-environment-occupation (PEO) model we aim to describe the relationship between frailty and life-space mobility in older adults. This manuscript provides a new framework for clinical practice and research implications of frailty and life-space mobility in older adults including: (1) overview of key concepts, (2) application of the PEO model to describe how frailty (personal) and life-space (environmental) can influence occupational performance, and (3) clinical practice implications to improve frailty-related immobility. This new framework provides a starting point to extend the focus of frailty beyond the individual to encompass the environmental context within which people live and move.

Background: The COVID-19 pandemic has placed significant pressure on health and social care. Survivors of COVID-19 may be left with substantial functional deficits requiring ongoing care. We aimed to determine whether pre-admission frailty was associated with increased care needs at discharge for patients admitted to hospital with COVID-19., Methods: Patients were included if aged over 18 years old and admitted to hospital with COVID-19 between 27 February and 10 June 2020. The Clinical Frailty Scale (CFS) was used to assess pre-admission frailty status. Admission and discharge care levels were recorded. Data were analysed using a mixed-effects logistic regression adjusted for age, sex, smoking status, comorbidities, and admission CRP as a marker of severity of disease., Results: Thirteen hospitals included patients: 1671 patients were screened, and 840 were excluded including, 521 patients who died before discharge (31.1%). Of the 831 patients who were discharged, the median age was 71 years (IQR, 58-81 years) and 369 (44.4%) were women. The median length of hospital stay was 12 days (IQR 6-24). Using the CFS, 438 (47.0%) were living with frailty (≥ CFS 5), and 193 (23.2%) required an increase in the level of care provided. Multivariable analysis showed that frailty was associated with an increase in care needs compared to patients without frailty (CFS 1-3). The adjusted odds ratios (aOR) were as follows: CFS 4, 1.99 (0.97-4.11); CFS 5, 3.77 (1.94-7.32); CFS 6, 4.04 (2.09-7.82); CFS 7, 2.16 (1.12-4.20); and CFS 8, 3.19 (1.06-9.56)., Conclusions: Around a quarter of patients admitted with COVID-19 had increased care needs at discharge. Pre-admission frailty was strongly associated with the need for an increased level of care at discharge. Our results have implications for service planning and public health policy as well as a person's functional outcome, suggesting that frailty screening should be utilised for predictive modelling and early individualised discharge planning.

Background: Frailty is common in cirrhosis and associated with mortality, hospitalization, and reduced quality of life. Interventions aimed at forestalling frailty are limited by a lack of understanding of underlying physiologic deficits., Aims: This study's aim was to examine contributions of discrete sensorimotor and neurocognitive capacities to conventional frailty measures of unipedal stance time, chair stands, and grip strength., Methods: This cross-sectional study enrolled 119 outpatients with cirrhosis (50% female, aged 62.9 ± 7.3 years). Capacities included sensory (lower limb sensation and visual contrast), neurocognitive (Number Connection Tests A and B, simple and recognition reaction time), and muscular (hip/core strength determined by lateral plank time (LPT)). Bivariate analyses and linear regression models were performed to identify significant contributors to each frailty measure., Results: The average performance was 9.8 ± 3.9 chair stands, 12.7 s ±9.9 unipedal stance time, and 60.3 ± 25.6 lb grip strength. In multivariate models, factors explained 40% of variance in unipedal stance and 43% of variance in chair stands. The LPT was most strongly associated with unipedal stance and chair stands. Grip strength was associated with LPT, but did not have physiologic predictors., Conclusions: Clinically useful measures of frailty in adults with cirrhosis can be explained by disease severity but also deficits in strength and neurocognitive function. Recognition reaction time, a novel measure in cirrhosis, had a significant contribution to frailty. These findings have implications for frailty assessment and suggest that the optimal rehabilitation approach to frailty targets neurocognitive function in addition to strengthening.

Background: A comprehensive geriatric assessment (CGA) of elderly patients is useful for detecting the patients vulnerabilities. Exercise and early rehabilitation, nutritional intervention, traditional Chinese medicine (TCM), standardized medication guidance, and patient education can, separately, improve and even reverse the physical frailty status. However, the effect of combining a CGA and multi-disciplinary management on frailty in elderly patients remains unclear. The present study assessed the effects of a CGA and multi-disciplinary management on elderly patients with frailty in China., Methods: In this study, 320 in patients with frailty ≥70 years old will be randomly divided into an intervention group and a control group. The intervention group will be given routine management, a CGA and multi-disciplinary management involving rehabilitation exercise, diet adjustment, multi-drug evaluation, acupoint massage in TCM and patient education for 12 months, and the control group will be followed up with routine management for basic diseases. The primary outcomes are the Fried phenotype and short physical performance battery (SPPB). The secondary outcomes are the clinical frailty scale (CFS), non-elective hospital readmission, basic activities of daily living (BADL), 5-level European quality of life 5 dimensions index (EQ-5D), nutrition risk screening-2002 (NRS-2002), medical insurance expenses, fall events, and all-cause mortality. In addition, a cost-effectiveness study will be carried out., Discussion: This paper outlines the protocol for a randomized, single-blind, parallel multi-center clinical study. This protocol, if beneficial, will demonstrate the interaction of various intervention strategies, will help improve elderly frailty patients, and will be useful for clinicians, nurses, policymakers, public health authorities, and the general population., Trial Registration: Chinese Clinical Trials Register, ChiCTR1900022623. Registered on April 19, 2019, http://www.chictr.org.cn/showproj.aspx?proj=38141.

Objectives: The advantages of social participation for older adults are well established and have been adopted in aging policy frameworks. However, little is known about the social participation of frail older adults. This research examined the types of social interaction of very frail older adults and the factors influencing this participation., Method: Interviews with 38 very frail older adults were analyzed using Levasseur and colleagues' (Levasseur, Richard, Gauvin, & Raymond (2010). Inventory and analysis of definitions of social participation found in the aging literature: Proposed taxonomy of social activities. Social Science and Medicine (1982), 71, 2141-2149) taxonomy activity levels of involvement with others. A qualitative hybrid approach with inductive and deductive thematic analyses was used., Results: Participants often disengaged from activities with high involvement with others, preferring activities with less involvement. Low-key participation emerged as an important type of social participation enabling frail older adults to remain engaged in society. Key factors that influenced social participation were functional decline, and the physical (e.g., traffic, the disappearance of local stores) and social environment (e.g., social networks and the presence of meeting places such as community centers)., Discussion: Findings advance our knowledge and recognition of the different ways frail older adults participate in society. Despite their frailty, older adults wish to stay socially active. Focusing on the social environment in the frameworks and policies of Age-Friendly Cities and Communities will benefit these individuals., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

One of the most widely conserved hallmarks of aging is a decline in functional capabilities. Mobility loss is particularly burdensome due to its association with negative health outcomes, loss of independence and disability, and the heavy impact on quality of life. Recently, a new condition, physical frailty and sarcopenia, has been proposed to define a critical stage in the disabling cascade. Physical frailty and sarcopenia are characterized by weakness, slowness, and reduced muscle mass, yet with preserved ability to move independently. One of the strategies that have shown some benefits in combatting mobility loss and its consequences for older adults is physical activity. Here, we describe the opportunities and challenges for the development of physical activity interventions in people with physical frailty and sarcopenia. The aim of this article is to review age-related physio(patho)logical changes that impact mobility in old age and to provide recommendations and procedures in accordance with the available literature., Competing Interests: All of the authors of the present work are partners of the SPRINTT consortium, which is partially funded by the European Federation of Pharmaceutical Industries and Associations (EFPIA). The authors report no potential conflicts of interest in this work., (© 2020 Billot et al.)

Purpose: This study aims to examine the frailty transition patterns of older adults recruited from both community and residential care settings within a 5-year period, and to identify the physical and psychosocial factors associated with the transitions., Design: This study is a secondary data analysis of a longitudinal study for tracking the change of health status of older adults 60 years of age or older. Participants who had undergone at least two assessments during 2013-2017 were selected for analysis. Guided by the Gobben's Frailty Model, biopsychosocial predictors were comprehensively identified from the literature, and their relationship to frailty state transition was explored., Methods: We compared the baseline characteristics of participants at the frail, pre-frail, and robust states (categorized using the Fried Frailty Index). A generalized estimating equation was used to identify factors associated with an improvement or a deterioration in frailty. The probability of transitions between frailty states was calculated., Findings: Among the 306 participants, 19% (n = 59) improved and 30% (n = 92) declined in frailty within the project period. Sleep difficulties (odds ratio [OR] = 1.76; 95% confidence interval [CI]: 1.07-2.90; p = .027), better cognitive status (OR = 0.80-0.84; 95% CI: 0.66-0.98 and 0.73-2.73; p = .031 and .018), good nutritional status (OR = 0.74; 95% CI: 0.59-0.91; p = .005), slow mobility (OR = 1.03-1.13; 95% CI: 1.00-1.05 and 1.03-1.25; p = .047 and .014), hearing impairment (OR = 2.83; 95% CI: 1.00-8.01; p = .05), better quality of health-physical domain (OR = 0.95; 95% CI: 0.92-0.99; p = .006), and better functional ability (OR = 0.85-0.97; 95% CI: 0.79-0.92 and 0.96-0.99; p < .001 and p = .003) were significant associated factors in the worsening group. More physical activity (OR = 1.01; 95% CI: 1.00-1.01 and 1.01-1.02; p = .026 and p < .001), hearing impairment (OR = 0.26; 95% CI: 0.08-0.86; p = .028), and slow mobility (OR = 0.93; 95% CI: 0.87-1.00; p = .037) were significant associated factors in the improvement group., Conclusions: Frailty is a crucial global public health issue. This study provides evidence for nurses to holistically consider the associated factors and to design effective interventions to combat frailty in our ageing society., Clinical Relevance: Frailty is a transient state that can be reversed. Professional nurses working in both community and residential care settings should be able to identify older adults at risk and improve their health conditions appropriately., (© 2020 Sigma Theta Tau International.)

Objective: To discuss the effects of elastic band exercise on the frailty states in pre-frail elderly people., Methods: This study was a randomized controlled trial. Trial registration number is ChiCTR-IOC-17012579. Seventy pre-frail elderly people were randomly divided into elastic band group ( n = 35) and control group ( n = 35). Elastic band exercise was applied to elastic band group, 45-60 min per time for 8 weeks by 3 days a week; no exercise was applied to the control group. The frailty states, grip strength (female/male), walking speed, and physical activity were measured by the Fried frailty phenotype at pre-intervention, 4, and 8 weeks after intervention to assess the effects of exercise., Results: The elastic band group showed significant improvements in the frailty states, grip strength (female) and walking speed both after 4-week and 8-week intervention ( P < 0.001), and significant improvements in grip strength (male) and physical activity after 8-week intervention ( P < 0.05). Within-group analysis (pre-intervention vs. after 4-week, after 4-week vs after 8-week, pre-intervention vs after 8-week) showed significant improvements ( P < 0.001) in grip strength (female/male) and walking speed in the elastic band group over time, while no significant differences in the control group ( P >  0.05)., Conclusion: Elastic band exercise can improve frailty states in pre-frail elderly people, make them broke away from pre-frailty and restore them to non-frailty through improving the grip strength, walking speed and physical activity, and the effects after 8 weeks are better than those after 4 weeks.

Background: Impaired physical mobility, most often seen in people with neurological disorders (i.e., stroke and spinal cord injury survivors), musculoskeletal diseases or frailty, is a limitation in independent and purposeful physical movement of the body or one or more extremities. The physical restrictions result in negative consequences on an individual's physical and psychosocial functions. This proposal describes a systematic review protocol to determine the effectiveness and approaches of sitting Tai Chi intervention for individuals with impaired physical mobility. Our review would inform stakeholders' decisions in integrating this complementary therapy into current rehabilitation services., Methods: Randomized controlled trials or quasi-experimental studies that compared an intervention group receiving sitting Tai Chi with a control group among adult participants with impaired physical mobility resulting from any health condition(s) will be included. Outcomes of interest will include physical and psychosocial health outcomes. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PubMed, CINAHL, Scopus, Web of Science, AMED, PsycINFO, SPORDiscus, PEDro, WanFang Data and China National Knowledge Infrastructure will be searched from their inception to January 2020. Additional searches will be performed to identify studies that are being refereed, to be published, unpublished or ongoing. Two reviewers will select the trials and extract data independently. The risk of bias of the included studies will be assessed using the Cochrane risk-of-bias tools. The Grading of Recommendations, Assessment, Development and Evaluation will be used to assess evidence quality for each review outcome. Data synthesis will be performed using Review Manager 5.3. When a meta-analysis is possible, we will assess the heterogeneity across the studies by computing the I statistics., Results: A high-quality synthesis of current evidence of sitting Tai Chi for impaired physical mobility will be stated from several aspect using subjective reports and objective measures of performance., Conclusion: This protocol will present the evidence of whether sitting Tai Chi is an effective intervention for impaired physical mobility., Prospero Registration Number: CRD 42019142681.

Background & Aims: Malnutrition, frailty, physical frailty, and disability are common conditions in patients with chronic obstructive pulmonary disease (COPD). Insight in the coexistence and relations between these conditions may provide information on the nature of the relationship between malnutrition and frailty. Such information may help to identify required interventions to improve the patient's health status. We therefore aimed to explore whether malnutrition, frailty, physical frailty, and disability coexist in patients with COPD at the start of pulmonary rehabilitation., Methods: For this cross-sectional study, from March 2015 to May 2017, patients with COPD were assessed at the start of a pulmonary rehabilitation program. Nutritional status was assessed with the Scored Patient-Generated Subjective Global Assessment (PG-SGA) based Pt-Global app. Frailty was assessed by the Evaluative Frailty Index for Physical activity (EFIP), physical frailty by Fried's criteria, and disability by the Dutch version of World Health Organization Disability Assessment Schedule 2.0 (WHODAS). These variables were dichotomized to determine coexistence of malnutrition, frailty, physical frailty, and disability. Associations between PG-SGA score and respectively EFIP score, Fried's criteria, and WHODAS score were analyzed by Pearson's correlation coefficient. Two tailed P-values were used, and significance was set at P < 0.05., Results: Of the 57 participants included (age 61.2 ± 8.7 years), malnutrition and frailty coexisted in 40%. Malnutrition and physical frailty coexisted in 18%, and malnutrition and disability in 21%. EFIP score and PG-SGA score were significantly correlated (r = 0.43, P = 0.001), as well as Fried's criteria and PG-SGA score (r = 0.37, P = 0.005)., Conclusions: In this population, malnutrition substantially (40%) coexists with frailty. Although the prevalence of each of the four conditions is quite high, the coexistence of all four conditions is limited (11%). The results of our study indicate that nutritional interventions should be delivered by health care professionals across multiple disciplines., (Copyright © 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Purpose: To examine the efficacy of an occupational therapy activity pacing intervention with deconditioned older adults in rehabilitation. Method: Randomised, single-blind controlled trial of deconditioned older adults admitted for rehabilitation following treatment of an acute medical condition, allocated to intervention [ n  = 51, males = 14, mean age = 80(8)] or control [ n  = 49, males = 12, mean age = 81(7)] group. The intervention group received individual and group activity pacing education with practice and application of techniques to daily activities and the home environment, while the control group received a typical occupational therapy program, which included brief activity pacing education. Outcomes included participation in daily living skills, health status (including pain and fatigue symptoms), self-efficacy in daily activities and activity pacing techniques using the Australian Therapy Outcome Measures-Occupational Therapy (AusTOMs-OT), Short Form-36 Health Survey (SF-36), Self-Efficacy Gauge and Activity Pacing Assessment. Results: No differences in groups at admission. Comparison at discharge and three months post discharge using 2 × 2 mixed ANOVA demonstrated small differences in only one scale of the activity limitation domain of the AusTOMs-OT. No significant differences were found in other scales or domains of the AusTOMs-OT, nor secondary outcome measures. Conclusion: Activity pacing in addition to typical occupational therapy during inpatient rehabilitation did not demonstrate benefits to participants in the management of their daily activities on returning home post hospitalisation.Implications for rehabilitationActivity pacing has been identified as one of the commonly used occupational therapy interventions utilised with deconditioned older adults in rehabilitation.An activity pacing intervention in conjunction with typical occupational therapy demonstrated no benefits for deconditioned older adults over typical occupational therapy which included basic education on this topic.Continuation of the activity pacing intervention into the outpatient setting may be of benefit to older adults and requires further investigation.

Background: Aim of the study was to find predictors of allocating patients after transcatheter aortic valve implantation (TAVI) to geriatric (GR) or cardiac rehabilitation (CR) and describe this new patient group based on a differentiated characterization., Methods: From 10/2013 to 07/2015, 344 patients with an elective TAVI were consecutively enrolled in this prospective multicentric cohort study. Before intervention, sociodemographic parameters, echocardiographic data, comorbidities, 6-min walk distance (6MWD), quality of life and frailty (score indexing activities of daily living [ADL], cognition, nutrition and mobility) were documented. Out of these, predictors for assignment to CR or GR after TAVI were identified using a multivariable regression model., Results: After TAVI, 249 patients (80.7 ± 5.1 years, 59.0% female) underwent CR (n = 198) or GR (n = 51). GR patients were older, less physically active and more often had a level of care, peripheral artery disease as well as a lower left ventricular ejection fraction. The groups also varied in 6MWD. Furthermore, individual components of frailty revealed prognostic impact: higher values in instrumental ADL reduced the probability for referral to GR (OR:0.49, p <  0.001), while an impaired mobility was positively associated with referral to GR (OR:3.97, p = 0.046). Clinical parameters like stroke (OR:0.19 of GR, p = 0.038) and the EuroSCORE (OR:1.04 of GR, p = 0.026) were also predictive., Conclusion: Advanced age patients after TAVI referred to CR or GR differ in several parameters and seem to be different patient groups with specific needs, e.g. regarding activities of daily living and mobility. Thus, our data prove the eligibility of both CR and GR settings.

Background: Cardiac rehabilitation is a mainstay treatment for patients experiencing an adverse cardiovascular event. Heart disease is important in frailty, but the impact of cardiac rehabilitation on frailty is unclear., Methods: Patients were referred to a 12-week group-based exercise and education cardiac rehabilitation program performed twice weekly. Frailty was measured with the use of a 25-item accumulation of deficits frailty index (range 0-1; higher values indicate greater frailty) at cardiac rehabilitation admission and completion. Patients were categorized by the degree of frailty in 0.1 increments., Results: Of the 4004 patients who enrolled, 2322 (58.0%) completed cardiac rehabilitation with complete data at admission and completion. There were 414 (17.8%), 642 (27.6%), 690 (29.7%), 401 (17.3%), and 175 (7.5%) patients with admission frailty levels of < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50, respectively. Frailty levels improved from cardiac rehabilitation admission (mean 0.34 [95% CI 0.32-0.35]) to completion (0.26 [0.25-0.28]) for those who completed the program (P < 0.001). After adjusting for age, sex, and number of exercise sessions attended, frailty improved in all frailty groups by mean differences of 0.03 (0.02-0.03), 0.05 (0.05-0.06), 0.08 (0.08-0.09), 0.10 (0.09-0.11), and 0.11 (0.10-0.13) in the < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50 frailty groups, respectively. The minimal improvement in frailty scores (≥ 0.03 reduction) was achieved by 48%, 65%, 72%, 76%, and 79% of patients in the the 5 frailty groups, respectively., Conclusions: Although higher frailty levels were associated with cardiac rehabilitation drop-out, finishing the program was related to improving frailty levels, especially in patients who were the frailest., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The elderly colorectal cancer patients tend to be frail, at nutrition risk with multiple comorbidities. In view of the stress on the body by surgery and recovery, it makes sense if patients are prepared before appropriately so that they can recover earlier and better. Prehabilitation prior to major surgery has attracted the attention of clinicians recently, and this review highlights the steps that need to be taken to implement a multidisciplinary program. Such programs requires a paradigm shift in the sense that all players need to be working in team for the benefit of patinets' outcome., Competing Interests: Declaration of competing interest Conflict of interest to be advised., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Introduction: Health professionals are progressively drawing on the concept of frailty as a determinant of adverse surgical outcomes in of older adults. We aimed to determine the prevalence of frailty and the correlation between frailty and mortality among older adults admitted to the acute surgical unit., Materials and Methods: This prospective cohort study was conducted in the acute general surgical unit over a two month period. We recruited 150 consecutive patients aged 65yrs and above. The modified frailty index was employed to measure frailty and the albumin levels on admission were obtained from electronic medical records. The patients were followed up for a period of thirty days., Results: We found that more than 40% of the older adults admitted to the acute general surgical unit were frail and frailty was associated with higher rate of mortality at 30 days. Hypoalbuminemia was associated with a longer length of stay, higher rate of complications, and an increased likelihood of discharge to a rehabilitation facility. There was also a significant univariate correlation between frailty and the presence of hypoalbuminemia on admission., Conclusion: Frailty and hypoalbuminemia are common in older general surgical patients and predict the likelihood of some of the adverse outcomes relevant to older adults and health economy such as mortality, increased length of stay, rate of complications, and likelihood of discharge to a rehabilitation facility. Further studies should investigate a possible causal association between frailty and low albumin levels in an acute surgical setting., (Copyright © 2019 SEGG. All rights reserved.)

Background: Higher protein intake is linked to maintenance of muscle mass and strength, but few studies have related protein to physical function and disability in aging., Methods: In participants of the Framingham Heart Study Offspring, we examined associations between protein intake (g/d), estimated from food frequency questionnaires, and maintenance of functional integrity, as a functional integrity score based on responses to 17 questions from Katz Activities of Daily Living, Nagi, and Rosow-Breslau questionnaires, repeated up to five times (1991/1995-2011/2014) over 23 years of follow-up. Cox proportional hazard models were used to estimate risk of incident loss of functional integrity (functional integrity score ≤ 15th percentile)., Results: In 2,917 participants (age 54.5 [9.8] years), baseline protein intake was 77.2 (15.6) g/d. The functional integrity score (baseline, mean 98.9, range 82.4-100.0) was associated with objective performance (gait speed, grip strength) and lower odds of falls, fractures, and frailty. Across follow-up, there were 731 incident cases of loss of functional integrity. In fully adjusted models, participants in the highest category of protein intake (median 92.2 g/d) had 30% lower risk of loss of functional integrity (hazard ratio [95% confidence interval] 0.70 [0.52, 0.95], p trend = .03), versus those with the lowest intake (median 64.4 g/d). However, sex-stratified analyses indicated the association was driven by the association in women alone (hazard ratio [95% confidence interval] 0.49 [0.32, 0.74], p trend = .002) and was nonsignificant in men (hazard ratio [95% confidence interval] 1.14 [0.70, 1.86], p trend = .59)., Conclusions: Higher protein intake was beneficially associated with maintenance of physical function in middle-aged, high-functioning U.S. adults over the span of two decades. This association was particularly evident in women., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Background: Older adults, who are living in nursing homes that provide a high level of long-term nursing care, are characterized by multimorbidity and a high prevalence of dependency in activities of daily living. Results of recent studies indicate positive effects of structured exercise programs during long-term care for physical functioning, cognition, and psychosocial well-being. However, for frail elderly the evidence remains inconsistent. There are no evidence-based guidelines for exercises for nursing home residents that consider their individual deficits and capacities. Therefore, high-quality studies are required to examine the efficacy of exercise interventions for this multimorbid target group. The purpose of this study is to determine the feasibility and efficacy of a multicomponent exercise intervention for nursing home residents that aims to improve physical and cognitive functioning as well as quality of life., Methods: A two-arm single-blinded multicenter randomized controlled trial will be conducted, including 48 nursing homes in eight regions of Germany with an estimated sample size of 1120 individuals. Participants will be randomly assigned to either a training or a waiting time control group. For a period of 16 weeks the training group will meet twice a week for group-based sessions (45-60 min each), which will contain exercises to improve physical functioning (strength, endurance, balance, flexibility) and cognitive-motor skills (dual-task). The intervention is organized as a progressive challenge which is successively adapted to the residents' capacities. Physical functioning, cognitive performance, and quality of life will be assessed in both study groups at baseline (pre-test), after 16-weeks (post-treatment), and after 32-weeks (retention test, intervention group only)., Discussion: This study will provide information about the efficacy of a multicomponent exercise program in nursing homes (performance, recruitment). Results from this trial will contribute to the evidence of multicomponent exercises, which specifically focus on cognitive-motor approaches in the maintenance of mental and physical functioning. In addition, it will help to encourage older adults to actively engage in social life. Furthermore, the findings will lead to recommendations for health promotion interventions for frail nursing home residents., Trial Registration: The trial was prospectively registered at DRKS.de with the registration number DRKS00014957 on October 9, 2018.