Effect of a multifactorial interdisciplinary intervention on mobility-related disability in frail older people: randomised controlled trial

Nicola Fairhall 0 2 Catherine Sherrington 2 Susan E Kurrle 1 Stephen R Lord 3 Keri Lockwood 1 Ian D Cameron 0 0 Rehabilitation Studies Unit, Sydney Medical School, The University of Sydney , Ryde, 2112 , Australia 1 Curran Ageing Research Unit, Division of Rehabilitation and Aged Care, Hornsby Ku-ring-gai Health Service , Hornsby, NSW , Australia 2 The George Institute for Global Health, The University of Sydney , Sydney, 2000 , Australia 3 Falls and Balance Research Group, Neuroscience Research Australia, University of New South Wales , Sydney, 2031 , Australia 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. - Background Frailty is a common geriatric syndrome, characterised by a vulnerability to adverse health outcomes including disability, hospitalisation and institutionalisation [1,2]. As the proportion of older people rises globally, the ability to function within society at increasing age is gaining importance, and the World Health Organization has called for research into disability in the vulnerable older population [3]. The International Classification of Functioning, Disability and Health [4] uses disability as an umbrella term for problems experienced by the individual at the level of the body (impaired body structure or function), the person (activity limitation), and the person in society (participation restriction). Frail older people experience disability at each of these levels; sarcopenia and muscle weakness are prevalent [1], limitations in performing activities (for example, walking, basic activities of daily living) are common [5,6], and 80% of frail older people experience restricted participation in life roles [7]. The ability to mobilise is particularly important in this vulnerable population, as gait speed is associated with mortality [8] and dependence in older people, yet the majority of frail older people walk more slowly than average [9] and report restricted mobility in the community [7]. There is little evidence to guide interventions to prevent or reduce mobility-related disability in frail older people, particularly in terms of participation in life roles. A recent systematic review of trials evaluating the effect of exercise interventions on disability outcomes in frail older people found that only three trials used a validated definition of frailty to categorise participants [10]. Clearly defined trial populations are needed for researchers and clinicians to extrapolate study results to frail older people. Few trials have evaluated disability outcomes at a societal level in terms of participation in life roles. Mobility outcomes are predominantly evaluated at the activity level (for example, speed of gait and stair climbing, basic activities of daily living) and the few studies that have measured participation in life roles used global measures that show participation across multiple domains of life [10], so the effect of intervention on participation in the mobility domain is unknown. Owing to its multifactorial aetiology, participation may be influenced by interventions despite the presence of irreversible health conditions, impairments and activity limitations [11]. Randomised controlled trials have demonstrated that the use of mobility aids by adults with limited mobility [12] and specific training of community interactions [13] increase mobility-related participation in adults. The optimal intervention to improve mobility-related participation in life situations remains unclear however, with few controlled trials. In a randomised controlled trial targeting the degree of frailty in frail older people [14], frailty was significantly reduced by a multifactorial interdisciplinary intervention (manuscript under review). In addition to targeting frailty, the intervention also addressed factors associated with mobility-related disability at the participation level (for example, home environment, social support, access to transport, mobility [15]) and the activity level (for example, balance, endurance). The intervention was tailored to address barriers to the mobility goal as nominated by each individual, consistent with an intervention that increased the extent of, and satisfaction with, outdoor mobility after a stroke [13]. The objective of this paper was to determine whether an interdisciplinary intervention specifically targeting frailty could reduce mobility-related disability, in terms of restricted participation in life roles and activity limitation, in community-dwelling frail older people. Methods Study design The Frailty Intervention Trial, a prospective, parallelgroup, assessor-blind, randomi (...truncated)