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Background and Objectives: There is a high prevalence of frailty amongst older patients in hospital settings. Frailty guidelines exist but implementation to date has been challenging. Understanding health professional attitudes, knowledge, and beliefs about frailty is critical in understanding barriers and enablers to guideline implementation, and the aim of this study was to understand these in rehabilitation multidisciplinary teams in hospital settings., Research Design and Methods: Twenty-three semistructured interviews were conducted with health professionals working in multidisciplinary teams on geriatric and rehabilitation wards in Adelaide and Sydney, Australia. Interviews were audio recorded, transcribed, and coded by 2 researchers. A codebook was created and interviews were recoded and applied to the Framework Method of thematic analysis., Results: Three domains were developed: diagnosing frailty, communicating about frailty, and managing frailty. Within these domains, 8 themes were identified: (1) diagnosing frailty has questionable benefits, (2) clinicians don't use frailty screening tools, (3) frailty can be diagnosed on appearance and history, (4) frailty has a stigma, (5) clinicians don't use the word "frail" with patients, (6) frailty isn't always reversible, (7) there is a lack of continuity of care after acute admission, and (8) the community setting lacks resources., Discussion and Implications: Implementation of frailty guidelines will remain challenging while staff avoid using the term "frail," don't perceive benefit of using screening tools, and focus on the individual aspects of frailty rather than the syndrome holistically. Clinical champions and education about frailty identification, reversibility, management, and communication techniques may improve the implementation of frailty guidelines in hospitals., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Objectives: Frailty is common in hospitalised older people. Clinical practice guidelines for the management of frailty provide recommendations for identification and management; however, adoption into practice in hospitals is limited. This study identified and quantified the evidence-practice gap between frailty guidelines and clinical practice in two hospitals using an audit tool., Methods: A cross-sectional audit of medical records of frail older patients admitted to two hospitals was conducted. Data were collected using an audit tool based on the Asia Pacific Clinical Practice Guidelines for frailty management. Data were analysed using descriptive statistics and inter-rater reliability of the tool was assessed., Results: Auditing of n = 70 electronic medical records showed that assessment of frailty in the acute setting did not regularly occur (17%). Few participants received guideline-recommended interventions. Physiotherapy treatment was limited, with 23% of participants receiving progressive resistance strength training. Gaps exist in provision of nutritional supplementation (26%) with limited recordings of weight during the admission for 10% of participants. Pharmacy review of medications was consistently documented on admission (84%) and discharge (93%). Vitamin D was prescribed for 57% of participants. Inter-rater reliability showed a high level of agreement using the audit tool., Conclusions: An audit tool was feasible to assess frailty evidence-practice gaps in the hospital setting. Further understanding of the contextual barriers is needed to inform implementation strategies (dedicated staffing, education and training and ongoing audit of practice cycles) for the uptake of frailty guidelines in hospital settings., (© 2024 The Authors. Australasian Journal on Ageing published by John Wiley & Sons Australia, Ltd on behalf of AJA Inc’.)

Objective: To empirically compare the measurement properties of the DEMQOL-U and DEMQOL-Proxy-U instruments to the EQ-5D-5L and its proxy version (CEQ-5D-5L) in a population of frail older people living in residential aged care in the post-hospitalisation period following a hip fracture., Methods: A battery of instruments to measure health-related quality of life (HRQoL), cognition, and clinical indicators of depression, pain and functioning were administered at baseline and repeated at 4 weeks' follow-up. Descriptive summary statistics were produced and psychometric analyses were conducted to assess the levels of agreement, convergent validity and known group validity between clinical indicators and HRQoL measures., Results: There was a large divergence in mean (SD) utility scores at baseline for the EQ-5D-5L and DEMQOL-U [EQ-5D-5L mean 0.21 (0.19); DEMQOL-U mean 0.79 (0.14)]. At 4 weeks' follow-up, there was a marked improvement in EQ-5D-5L scores whereas DEMQOL-U scores had deteriorated. [EQ-5D-5L mean 0.45 (0.38); DEMQOL-U mean 0.58 (0.38)]. The EQ-5D and CEQ-5D-5L were more responsive to the physical recovery trajectory experienced by frail older people following surgery to repair a fractured hip, whereas the DEMQOL-U and DEMQOL-Proxy-U appeared more responsive to the changes in delirium and dementia symptoms often experienced by frail older people in this period., Conclusions: This study presents important insights into the HRQoL of a relatively under-researched population of post-hospitalisation frail older people in residential care. Further research should investigate the implications for economic evaluation of self-complete versus proxy assessment of HRQoL and the choice of preference-based instrument for the measurement and valuation of HRQoL in older people exhibiting cognitive decline, dementia and other co-morbidities.

Question: What is the effect of a multifactorial intervention on frailty and mobility in frail older people who comply with their allocated treatment?, Design: Secondary analysis of a randomised, controlled trial to derive an estimate of complier average causal effect (CACE) of treatment., Participants: A total of 241 frail community-dwelling people aged ≥ 70 years., Intervention: Intervention participants received a 12-month multidisciplinary intervention targeting frailty, with home exercise as an important component. Control participants received usual care., Outcome Measures: Primary outcomes were frailty, assessed using the Cardiovascular Health Study criteria (range 0 to 5 criteria), and mobility measured using the 12-point Short Physical Performance Battery. Outcomes were assessed 12 months after randomisation. The treating physiotherapist evaluated the amount of treatment received on a 5-point scale., Results: 216 participants (90%) completed the study. The median amount of treatment received was 25 to 50% (range 0 to 100). The CACE (ie, the effect of treatment in participants compliant with allocation) was to reduce frailty by 1.0 frailty criterion (95% CI 0.4 to 1.5) and increase mobility by 3.2 points (95% CI 1.8 to 4.6) at 12 months. The mean CACE was substantially larger than the intention-to-treat effect, which was to reduce frailty by 0.4 frailty criteria (95% CI 0.1 to 0.7) and increase mobility by 1.4 points (95% CI 0.8 to 2.1) at 12 months., Conclusion: Overall, compliance was low in this group of frail people. The effect of the treatment on participants who comply with allocated treatment was substantially greater than the effect of allocation on all trial participants., Trial Registration: Australian and New Zealand Trial Registry ANZCTRN12608000250336. [Fairhall N, Sherrington C, Cameron ID, Kurrle SE, Lord SR, Lockwood K, Herbert RD (2016) A multifactorial intervention for frail older people is more than twice as effective among those who are compliant: complier average causal effect analysis of a randomised trial.Journal of Physiotherapy63: 40-44]., (Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Introduction: Frailty is a major concern due to its costly and widespread consequences, yet evidence of effective interventions to delay or reduce frailty is lacking. Our previous study found that a multifactorial intervention was feasible and effective in reducing frailty in older people who were already frail. Identifying and treating people in the pre-frail state may be an effective means to prevent or delay frailty. This study describes a randomised controlled trial that aims to evaluate the effectiveness of a multifactorial intervention on development of frailty in older people who are pre-frail., Methods and Analysis: A single centre randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Two hundred and thirty people aged above 70 who meet the Cardiovascular Health Study frailty criteria for pre-frailty, reside in the community and are without severe cognitive impairment will be recruited. Participants will be randomised to receive a multifactorial intervention or usual care. The intervention group will receive a 12-month interdisciplinary intervention targeting identified characteristics of frailty and problems identified during geriatric assessment. Participants will be followed for a 12-month period. Primary outcome measures will be degree of frailty measured by the number of Cardiovascular Health Study frailty criteria present, and mobility measured with the Short Physical Performance Battery. Secondary outcomes will include measures of mobility, mood and use of health and community services., Ethics and Dissemination: The study was approved by the Northern Sydney Local Health District Health Research Ethics Committee (1207-213M). The findings will be disseminated through scientific and professional conferences, and in peer-reviewed journals., Trial Registration Number: Australian New Zealand Clinical Trials Registry: ACTRN12613000043730., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To compare the costs and cost-effectiveness of a multifactorial interdisciplinary intervention versus usual care for older people who are frail., Design: Cost-effectiveness study embedded within a randomized controlled trial., Setting: Community-based intervention in Sydney, Australia., Participants: A total of 241 community-dwelling people 70 years or older who met the Cardiovascular Health Study criteria for frailty., Intervention: A 12-month multifactorial, interdisciplinary intervention targeting identified frailty characteristics versus usual care., Measurements: Health and social service use, frailty, and health-related quality of life (EQ-5D) were measured over the 12-month intervention period. The difference between the mean cost per person for 12 months in the intervention and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated., Results: A total of 216 participants (90%) completed the study. The prevalence of frailty was 14.7% lower in the intervention group compared with the control group at 12 months (95% CI 2.4%-27.0%; P = .02). There was no significant between-group difference in EQ-5D utility scores. The cost for 1 extra person to transition out of frailty was $A15,955 (at 2011 prices). In the "very frail" subgroup (participants met >3 Cardiovascular Health Study frailty criteria), the intervention was both more effective and less costly than the control. A cost-effectiveness acceptability curve shows that the intervention would be cost-effective with 80% certainty if decision makers were willing to pay $A50,000 per extra person transitioning from frailty. In the very frail subpopulation, this reduced to $25,000., Conclusion: For frail older people residing in the community, a 12-month multifactorial intervention provided better value for money than usual care, particularly for the very frail, in whom it has a high probability of being cost saving, as well as effective. Trial registration: ACTRN12608000250336., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Rehabilitation approaches to frailty are in the early stages of development. Frailty also shows promise as a prognostic indicator for rehabilitation programs, similar to its application in other areas of medicine. However, care should be taken not to exclude frail older people from rehabilitation, as has been the case at some centers for people with cognitive impairment or very severe disability. There are clear theoretical reasons to expect that a rehabilitation approach will be effective. Some experimental data are also available suggesting that rehabilitation is effective in frail and pre-frail older people. The principles of a frailty intervention program that have been demonstrated to be clinically and economically effective are as follows: first, frailty can be mitigated; second, support needs are individually addressed; third, the interventions aim to improve physical, cognitive and social functioning; fourth, support has to be delivered over a long time period; and finally, systems must facilitate consistent management. Most frail older people are encouraged and supported to adhere to their intervention plan. It is important to recognize the needs of families and/or carers and to engage with them., (2015 S. Karger AG, Basel.)

Background: frail older people have a high risk of falling., Objective: assess the effect of a frailty intervention on risk factors for falls and fall rates in frail older people., Design: randomised controlled trial., Participants: 241 community-dwelling people aged 70+ without severe cognitive impairment who met the Cardiovascular Health Study frailty definition., Intervention: multifactorial, interdisciplinary intervention targeting frailty characteristics with an individualised home exercise programme prescribed in 10 home visits from a physiotherapist and interdisciplinary management of medical, psychological and social problems., Measurements: risk factors for falls were measured using the Physiological Profile Assessment (PPA) and mobility measures at 12 months by a blinded assessor. Falls were monitored with calendars., Results: participants had a mean (SD) age of 83.3 (5.9) years, 68% were women and 216 (90%) completed the study. After 12 months the intervention group had significantly better performance than the control group, after controlling for baseline values, in the PPA components of quadriceps strength (between-group difference 1.84 kg, 95% CI 0.17-3.51, P = 0.03) and body sway (-90.63 mm, 95% CI -168.6 to -12.6, P = 0.02), short physical performance battery (1.58, 95% CI 1.02-2.14, P ≤ 0.001) and 4 m walk (0.06 m/s 95% CI 0.01-0.10, P = 0.02) with a trend toward a better total PPA score (-0.40, 95% CI -0.83-0.04, P = 0.07) but no difference in fall rates (incidence rate ratio 1.12, 95% CI 0.78-1.63, P = 0.53)., Conclusion: the intervention improved performance on risk factors for falls but did not reduce the rate of falls., Trial Registration: ACTRN12608000250336., (© The Author 2013. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@ oup.com.)

Background: Frailty is a well known and accepted term to clinicians working with older people. The study aim was to determine whether an intervention could reduce frailty and improve mobility., Methods: We conducted a single center, randomized, controlled trial among older people who were frail in Sydney, Australia. One group received an intervention targeting the identified characteristics of frailty, whereas the comparison group received the usual health care and support services. Outcomes were assessed by raters masked to treatment allocation at 3 and 12 months after study entry. The primary outcomes were frailty as assessed by the Cardiovascular Health Study criteria, and mobility as assessed by the Short Physical Performance Battery. Secondary outcome measures included disability, depressive symptoms and health-related quality of life., Results: A total of 216 participants (90%) completed the study. Overall, 68% of participants were women and the mean age was 83.3 years (standard deviation, 5.9). In the intention-to-treat analysis, the between-group difference in frailty was 14.7% at 12 months (95% confidence interval: 2.4%, 27.0%; P = 0.02). The score on the Short Physical Performance Battery, in which higher scores indicate better physical status, was stable in the intervention group and had declined in the control group; with the mean difference between groups being 1.44 (95% confidence interval, 0.80, 2.07; P <0.001) at 12 months. There were no major differences between the groups with respect to secondary outcomes. The few adverse events that occurred were exercise-associated musculoskeletal symptoms., Conclusions: Frailty and mobility disability can be successfully treated using an interdisciplinary multifaceted treatment program., Trial Registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000250336.

Background: Interventions that enhance mobility in frail older people are needed to maintain health and independence, yet definitive evidence of effective interventions is lacking. Our objective was to assess the impact of a multifactorial intervention on mobility-related disability in frail older people., Methods: We conducted a randomised, controlled trial with 241 frail community-dwelling older people in Sydney, Australia. Participants were classified as frail using the Cardiovascular Health Study definition, did not have severe cognitive impairment and were recently discharged from an aged care and rehabilitation service. The experimental group received a 12 month multifactorial, interdisciplinary intervention targeting identified frailty components. Two physiotherapists delivered a home exercise program targeting mobility, and coordinated management of psychological and medical conditions with other health professionals. The control group received usual care. Disability in the mobility domain was measured at baseline and at 3 and 12 months using the International Classification of Functioning, Disability and Health framework. Participation (involvement in life situations) was assessed using the Life Space Assessment and the Goal Attainment Scale. Activity (execution of mobility tasks) was measured using the 4-metre walk and self-report measures., Results: The mean age of participants was 83.3 years (SD: 5.9 years). Of the participants recruited, 216 (90%) were followed-up at 12 months. At this time point, the intervention group had significantly better scores than the control group on the Goal Attainment Scale (odds ratio 2.1; 95% confidence interval (CI) 1.3 to 3.3, P = 0.004) and Life Space Assessment (4.68 points, 95% CI 1.4 to 9.9, P = 0.005). There was no difference between groups on the global measure of participation or satisfaction with ability to get out of the house. At the activity level, the intervention group walked 0.05 m/s faster over 4 m (95% CI 0.0004 to 0.1, P = 0.048) than the control group, and scored higher on the Activity Measure for Post Acute Care (P < 0.001)., Conclusions: The intervention reduced mobility-related disability in frail older people. The benefit was evident at both the participation and activity levels of mobility-related disability., Trial Registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ANZCTRN12608000507381.

Frailty is a common syndrome that is associated with vulnerability to poor health outcomes. Frail older people have increased risk of morbidity, institutionalization and death, resulting in burden to individuals, their families, health care services and society. Assessment and treatment of the frail individual provide many challenges to clinicians working with older people. Despite frailty being increasingly recognized in the literature, there is a paucity of direct evidence to guide interventions to reduce frailty. In this paper we review methods for identification of frailty in the clinical setting, propose a model for assessment of the frail older person and summarize the current best evidence for treating the frail older person. We provide an evidence-based framework that can be used to guide the diagnosis, assessment and treatment of frail older people.

Background: Frailty is a term commonly used to describe the condition of an older person who has chronic health problems, has lost functional abilities and is likely to deteriorate further. However, despite its common use, only a small number of studies have attempted to define the syndrome of frailty and measure its prevalence. The criteria Fried and colleagues used to define the frailty syndrome will be used in this study (i.e. weight loss, fatigue, decreased grip strength, slow gait speed, and low physical activity). Previous studies have shown that clinical outcomes for frail older people can be improved using multi-factorial interventions such as comprehensive geriatric assessment, and single interventions such as exercise programs or nutritional supplementation, but no interventions have been developed to specifically reverse the syndrome of frailty.We have developed a multidisciplinary intervention that specifically targets frailty as defined by Fried et al. We aim to establish the effects of this intervention on frailty, mobility, hospitalisation and institutionalisation in frail older people., Methods and Design: A single centre randomised controlled trial comparing a multidisciplinary intervention with usual care. The intervention will target identified characteristics of frailty, functional limitations, nutritional status, falls risk, psychological issues and management of chronic health conditions. Two hundred and thirty people aged 70 and over who meet the Fried definition of frailty will be recruited from clients of the aged care service of a metropolitan hospital. Participants will be followed for a 12-month period., Discussion: This research is an important step in the examination of specifically targeted frailty interventions. This project will assess whether an intervention specifically targeting frailty can be implemented, and whether it is effective when compared to usual care. If successful, the study will establish a new approach to the treatment of older people at risk of further functional decline and institutionalisation. The strategies to be examined are readily transferable to routine clinical practice and are applicable broadly in the setting of aged care health services., Trial Registration: Australian New Zealand Clinical Trails Registry: ACTRN12608000250336.

To the authors' knowledge, no study has been conducted on life expectancy for aged care facility residents with hip fracture. We assessed life expectancy of 240 residents of aged care facilities in Australia who experienced recent hip fracture treated with surgery. 149 deaths occurred over a mean follow-up of 1.2 years. Being female and having better cognition were associated with longer life expectancy. Increased age was associated with shorter life expectancy. The cumulative mortality rate within three months after hip fracture was 25.0% while the cumulative mortality rate for the whole study period was 62.1%. Life expectancy was 8.2 years, 4.8 years and 2.8 years for 70, 80 and 90-years old female patients. Life expectancy was 3.8 years, 2.2 years and 1.3 years for 70, 80 and 90 years old male patients, respectively. In conclusion, age, gender and cognition level were associated with life expectancy of hip fracture patients living in aged care facilities and their life expectancy was much shorter than that of the general Australian population. [ABSTRACT FROM AUTHOR]

The rehabilitation of people with frailty takes time,5 and hospitals are under pressure to reduce patients' stays in hospital (the median rehabilitation length of stay reported by Soh and his co-authors was 20 days1). Key priorities are to build the capacity and competence of primary health services to provide general rehabilitation services to older people, and to improve networking of and collaboration between primary care and specialist rehabilitation units. Some health services have worked through these intersectoral problems and have articulated a model that could be implemented broadly in Australia.11 Australia urgently needs a national rehabilitation strategy to reduce overreliance on hospital services for functional recovery and rehabilitation treatments. [Extracted from the article]

Questions: What walking aid prescription occurs at discharge after hip fracture? What changes in walking aid use occur in the following six months? Who initiates changes in walking aids and why? Design: Prospective longitudinal observational study. Participants: 95 community-dwelling older adults who had undergone surgical treatment of a hip fracture. Outcome measures: Range of walking aids prescribed at discharge and participants' recall of advice about progression were recorded. Progression of walking aids was observed fortnightly over 6 months. With any change in walking aid use, an independent physiotherapist determined if it was appropriate and participants reported the reason for the change. Results: Most participants were discharged from their final inpatient setting with a wheeled frame (92%). Eighty-two (86%) participants were not aware of any goals set by the physiotherapist for the first 6 months and 89 (94%) stated that a review time had not been set. Despite this, 78 (82%) participants changed their walking aid, on average 8 weeks (SD 6) after discharge. However, 32% of those who changed their walking aids were using an inappropriate aid or using it incorrectly. Six months after discharge, 40% of participants had not returned to using their pre-morbid indoor aid and 50% their outdoor aid. Conclusion: A review of walking aid by a physiotherapist is rare within six months after discharge following hip fracture. Most patients make their own decision about what walking aid is most appropriate. This has safety implications in a group at high risk of falls. [ABSTRACT FROM AUTHOR]

Objective: To determine the effectiveness of interdisciplinary rehabilitation for women with hip fracture who were residents of nursing homes. Design: Randomised controlled trial. Subjects: Eleven cognitively impaired women with hip fracture who were previously ambulant. Methods: Participants were randomly allocated to usual care (discharge back to the nursing home soon after surgery to the hip fracture) or an inpatient interdisciplinary rehabilitation program. Results: Participants were severely cognitively impaired and the majority used a walking aid prior to fracturing their hip. There was one early death, and at final follow up (4 months after hip fracture) median (range) Barthel Index was 28 (0–82) for control group and 68 (0–88) for the intervention group. Conclusion: No definite conclusion can be drawn about the effectiveness of the intervention because of its premature termination. However, the study established that it is feasible to provide an interdisciplinary rehabilitation for older people with hip fracture and severe disablement. [ABSTRACT FROM AUTHOR]