Understanding frailty and sarcopenia

---

Understanding Frailty


Working Out to Combat Frailty


Brain-training to Combat Frailty


Understanding Sarcopenia


Reverse Sacropenia by Muscle Building Excerise


Preventing Sarcopenia


Frailty and sarcopenia

---

Content

• What is healthy ageing?
• What is frailty?
• How to identify frailty?
• What is sarcopenia?
• How to diagnose sarcopenia?
• Interventions for frailty and sarcopenia

---

What is Healthy Ageing?

Process of developing and maintaining functional ability that enables well being of older age (WHO, 2020)

Image source from : https://www.hkhs.com/en/our-business/elderly-housing

---

• The HIGHLIGHT ---- Focus on Functioning

  ie. Interactions between individual (intrinsic capacity) and the environment (including physical environment and supporting systems)

Image source from : https://www.futuregen.solutions/2016/08/16/the-shameful-case-of-elder-abuse-in-society/ &
https://thediplomat.com/2019/11/how-does-japans-aging-society-affect-its-economy/

---

---

Intrinsic Capacity and function

A-B: denotes impact of environmental factors C-D: higher baseline level allows more reserve to lose before requiring assistance E: Accelerated decline because unfavourable lifestyle or disease state F: restoration / reversal attempts

---

Healthy Ageing:
Building up intrinsic capacity / slow down decline

Modifiable factors Healthy dieting and good nutrition (cross ref to Chapter 2) Regular exercise / physical activities (cross ref to Chapter 3) Maintain mental health Disease prevention / good disease control Active life engagement with others and society

Non-modifiable factors Genetic composition Sex Chronological age

---

From Healthy Ageing to Frailty

---

Convention scientific approach

Image source from : http://www.intra-lifestyles.eu/intra-supports-bodys-eight-8-biological-systems/

Individual system Individual disease One man, one disease model Linear model (A ➡ B) Individual disease management

---

Limitations on use of conventional approach to older adults (1)

No tissue /system is free from ageing (though varies between individual, and among organs of same individual) With age, increase in multi-system (instead of single disease / system) involvement leading to ➡ function limitation

---

Limitations on use of conventional approach to older adults (2)

Proper functioning (remember: WHO defines health in term of functioning) depends on multiple systems interacting together A person may have reduced exercise capacity because of heart problem, lung problem, joint problem, muscle problem, mood problem, or any combinations of each of the problems in variable degree Convention single disease model has great limitation in older adults

---

Knowledge from animal studies

Caloric Restriction in mice • Extended life span by 50% • Die without apparent diseases

Measurement on number of dysfunctions (irrespective of which) predictive of death

https://www.scmp.com/lifestyle/health-wellness/article/3153010/ & https://www.science.org/content/article/

---

---

• Physique and bodily function among individuals vary with age
• Many a time, multiple components of which each alone with little impact, contribute to the impairment
• More commonly observe in older adults, yet not exclusive (ie. above can be observed in younger population)

➡ (development of) FRAILTY SYNDROME

---

Frailty Syndrome

---

Frailty represented by two ways

• Phenotypic frailty (Fried et al., 2001)

  • Unintentional weight loss
  • Self reported exhaustion
  • Weakness (Grip strength)
  • Slow walking speed
  • Low physical activity

• Culminative deficits (Rockwood & Mitnitski, 2007)

  • Deficit accumulation of multiple etiologies
  • Reduced reserved (intrinsic capacity)
  • Increased vulnerability to stress

---

Ageing and Frailty

Multi-dimensional aspect of health Gradual decline over time High intrinsic capacity / resilience ➡ protect from frailty ➡ healthy aging Any breakdown ➡ accelerated decline and dependency

Image source from : https://www.hindawi.com/journals/jar/2019/2573239/

---

Key concepts in Frailty
(multiple physiological systems)

Though it may manifest as a physical dimension (e.g. walking problems), underlying issues are multi-dimension and can go across cognitive and social dimension For research purposes, some authors would like to classify Frailty into • Physical frailty • Cognitive frailty • Social frailty (Let's focus on healthcare related aspects of frailty) Image source from : https://www.researchgate.net/figure/fig1_318351153

---

Key Concepts (decline in reserve)

Image source from : https://link.springer.com/chapter/10.1007/978-981-13-8938-2_1

A decline in intrinsic capacity (reserve) over time (see previous slide) Implication • There exists "sub-clinical" ("Pre-frail") with diminishing reserve yet not manifested ➡ allow window time to detect and reverse

---

Key Concepts in Frailty
(Biological but not chronological age)

Although frailty will ultimately set in (unless one dies early), it can be delayed with healthy ageing activities till very old (see previous slide) Biological age is more important than chronologic age

Image source from : https://vee-uye.com/

---

Impacts of Frailty

Image source from : https://vee-uye.com/

It is associated with adverse outcome • Slower recovery rate • May not recover to as before • Excess mortality Precipitation of geriatric syndrome • Delirium • Falls • Failure to thrive • Immobility, not coping / dependency Importance on early identification for • Preventing complications • Optimize management plan (to be discussed later)

---

Key concept in Frailty
(frailty and functioning)

• Disability / limitation in self care
• Sarcopenia (loss of muscle and loss of function) (to be discussed later)

---

Disability and Frailty
... Imagine two persons who cannot walk without aids

• Baseline: independent
• Road traffic accident with below knee amputation (BKA)
• Disability in ambulation: Walks with prothesis or hop with elbow crutches

• Baseline: osteoarthritis right knee, used to walk slowly
• Now has a cerebrovascular accident with right side lower limb power 4/5
• Sustain fracture hip during acute CVA with leg length discrepancy
• Disability in ambulation: walks with frame

• Are the mechanisms leading to the disability similar?

---

Disability and Frailty...

---

• Is NOT frail though loss of ambulation (self care limitation, disability) because of single factor involvement (loss of leg as support)

---

---

• For each of the risk factor alone (OA knee, CVA, leg length discrepancy) , B may still manage to walk with compensatory mechanism
• Yet, the multiple little impairment in each aspect contribute to the inability to walk (ie. loss of reciprocal compensation)
• B has frailty because lack of reserve and function across multiple physiological system

---

---

Key Concepts (frailty ≠ disabilities)

---

---

How common is Frailty?

Depends on criteria, setting and groups of subjects chosen • US (Fried et al., 2012) 9.9% • Asia Pacific region 3.5 – 27% • Hong Kong (Woo et al., 2015) 12.5% • Singapore (Chong et al., 2017) 6%

---

(Woo et al., 2015)
Robust = FRAIL score 0, Prefrail = FRAIL score 1-2, Frail = FRAIL score 3-5
FRAIL score to be discussed at later slides

---

Screening for frailty – Who and How?

---

The "How"?

Multiple Screening tools – some examples • Frailty phenotype (Fried) • Frailty Index (Rockwood) • Clinical Frailty Scale (Rockwood) • "FRAIL" scale (Moley) • Edmonton Frail Scale (Rolfson) • Tilburg frailty indicator (Gobbens)

---

Frailty phenotype (Fried et al., 2001)

---

Frailty Index (Rockwood et al., 2005)

• Based on accumulation of deficits model

• •  FI =

  Number of deficit   Total number of item

• Items measured

  • At least 30-40 items

• Criteria for items to be included

  • Associated with health
  • In general, the deficit should increase with age
  • Deficit should not be saturated too early
  • Cover a range of conditions

• Can be symptom (e.g. easy fatigue), sign, laboratory result (e.g. DM) ,
  disability (e.g. manage finance) , disease (e.g. CVA) 

---

Clinical Frailty Scale (Rockwood et al., 2005)

---

CFS in practice (Chong et al., 2021) 

Image source from : https://www.jamda.com/article/S1525-8610(21)00203-6/fulltext

---

FRAIL scale (Morley)

---

Edmonton frail scale

---

Image source from : https://ihub.scot/improvement-programmes/community-care/electronic-frailty-index-efi/

---

How to choose among different tools?

---

Who to be screened?

• Primary Care setting

  • All persons age >70 
  • Those with multiple chronic illnesses
  • Those who have weight loss over 5kg in past one year
  • (FRAIL scale most applicable)   

  (Dent et al., 2017)

• Opportunistic screening among age >65
• Use of validated tool of your setting

  • CFS, eFI, EFS, Culminative Deficit Score of your setting

  (Dent et al., 2019) 

---

Why screen for Frailty?

Restoration

Frailty is reversible (Lee et al., 2014) ➡ Screening for intervention and restoration  (How? to be discussed later)

---

Prevention of complication at stress

• Precipitation of geriatric syndrome

  • Delirium
  • Falls
  • Failure to thrive malnourishment
  • Immobility, not coping / dependency

➡ hospital related complication
➡ prolonged recovery time
➡ prolonged hospital stay

• Early identification

  ➡ Action for prevention

---

Why screen for frailty?
Optimize management plan

Robust person longer quality life years ➡ More benefit to Rx More resilient to stress ➡ Less risk to Rx

Frail person Shorter quality life year ➡ Less benefit to Rx Less resilient to stress ➡ Higher risk to Rx

For same condition More acceptable to subject a robust person to Rx that have higher efficacy though may have higher procedure / Rx risk More acceptable to subject a frail person to Rx that is of lesser risk though lesser efficacy

---

Optimize management plan (Example)

• Benefit / risk assessment for management of severe aortic stenosis
  (Asgar et al., 2019)

---

Optimize management plan 

---

Optimize management plan 

• Pre-operative

  • Optimize background condition
  • Medication review
  • Nutrition augmentation
  • Rehabilitation

• Enhance postoperative care

  • Pressure sore prevention
  • Delirium prevention
  • Attention to hydration, nutrition
  • Early mobilization

---

Why screen for frailty?
Optimize management

• Identify (multi-dimensional) support care needs for ageing in place image source from : https://www.researchgate.net/figure/fig1_318351153

---

Let's move to sarcopenia for time being

---

Sarcopenia and frailty

---

Definition of sarcopenia

A syndrome characterized by • Low muscle strength • Low muscle quality and / or quantity (Cruz-Jentoft et al., 2019) "Probable" sarcopenia • Low muscle strength alone Severe sarcopenia • Physical performance Implication • Risk of adverse outcomes such as physical disability, poor quality of life and mortality

---

• Age-related loss of skeletal mass
Plus
• Loss of skeletal strength
And / Or
• Reduced performance  

Severe sarcopenia = reduced loss of mass + strength + performance  (Chen et al., 2020)

---

How common is sarcopenia?
(community living seniors)

---

SARC-F for screening of sarcopenia
(community setting)

---

Community Screening for sarcopenia (Flow)

Remarks: (1) Definite diagnosis requires measure of appendicular skeletal muscle by DEXA (2) Possible sarcopenia - Either one of Handgrip / Performance +ve : (3) Likely severe sarcopenia - Both handgrip and performance +ve (4) Benefit for intervention once possible sarcopenia is established

(Chen et al., 2020)

---

Triggers for screening in clinical settings

• Presence of

  • Functional decline or limitation, unintentional weight loss, depressive mood, cognitive impairment, repeated falls, malnutrition
  • Chronic conditions (heart failure, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease etc)

(Chen et al., 2020)

---

What to do after diagnosis of Sarcopenia / Frailty 

---

A recap on their relationship

 (Cruz-Jentoft et al., 2019)

---

A recap on their relationship

(Bentov et al., 2019)

---

---

What to do after diagnosis of
sarcopenia and / or frailty?

Review for possible secondary causes • Intentional weight loss / dietary restriction • Review intake and contribution factor (e.g. social isolation with malnutrition, poor denture)  • Review control of medical conditions (e.g. DM) • Review medication list to avoid iatrogenesis (e.g. hypotension)  • Review lifestyle • sedentary lifestyle predisposed to accelerated muscle loss • fatigue from disease (e.g. anemia, hypothyroid, depression)

---

STRONG Recommendations for primary sarcopenia / frailty • (Graded) Resistive exercise to improve muscle mass and strength (eg. Vivifrail exercise) • Protein / caloric supplementation with high protein diet • To couple with resistive exercise • Up to 1.2gm/kg/day • Vitamin D supplement if Vitamin D deficit

---

---

• Conditional recommendation (preliminary data available but need further studies) on individual nutrient supplements

  • Vitamin D if not at deficit state
  • B-hydroxy B-methylbutyrate (HMB) (an essential amino acid)
  • Whey protein after resistive exercise

---

The above resistive exercise and high protein diet tackles physical frailty Psychological frailty, and social frailty need to be addressd

---

Psychological Frailty

• Refers to impairments in various areas, such as mood, cognition and motivational components
• A consequence of age-altered brain function
• Reduction in cognitive reserve>>>cognitive frailty
• Loss of resilience and adaptability in the domain of brain function
• Physical frailty has implication in cognitive function
       >>>   health outcomes   
  (Fitten, 2015)

---

Cognitive Frailty

The concept of cognitive frailty

• linked to a reduction in cognitive 'reserve';
• characterized by the coexistence of physical frailty and cognitive impairment (Clinical Dementia Rating [CDR] = 0.5);
• and exclusion of concurrent Alzheimer's disease or other dementias (Kelaiditi et al., 2013)

---

Social Frailty

• A state of being at risk of losing (or having already lost) resources that are essential for meeting one or more basic social demands.
• Living alone, not having a friend and family support, socially isolated could have a severe impact on psychological well-being.

---

Interventions

• Aim to improve psychosocial wellbeing concerning emotion, social, mental and spiritual domains
• Long term community-based with multidimensional training activities
• Cognitive Training

  • Enhance attention and information processing, stimulate short-term memory, reasoning and problem-solving abilities
  • Gerontecnology e.g. computer games, VR programme etc.
  Click here for more information

• Age-friendly community

  • Create supportive environment
  • Community resources

  
  
  Facilitating frail older adults in social participation
  
• Social inclusion and participation

  • Paid or unpaid work
  • Enhance social connections

• Social campaigns

  • Arouse public awareness of age-related frailty and pre-frailty
  • Early identification and intervention

• Improve resilience

  • Increase intrinsic capabilities to cope with stressors

• Suggest healthy lifestyle to avoid or delay decline

---

Better still ... to improve resilience

---

---

Suggested reading

Professional training materials of Cadenza Training programme

• Promoting Psychosocial and Spiritual Well-being of Older People

---

Reference

---

- End of Chapter 1 -

---

Nutrition intervention for frailty and sarcopenia

• Sarcopenia and physical frailty share many clinical features, including loss of muscle strength, functional decline, and body shrinking
• Similar nutritional strategies can be adopted for the management of sarcopenia and physical frailty

---

A. Preventing physical frailty and sarcopenia with nutrition

Preventing frailty and sarcopenia with nutrition

---

1. Adequate energy intake

• Food consumed is metabolized to provide energy for organ function and muscle activity
• Insufficient energy intake ➡ body fat and muscle are catabolized to provide energy
• How do I know if someone's energy intake is (in)adequate?

  ✔ Any unintentional weight loss?
  - % weight change = (current weight – previous weight) / current weight x 100.
  - >5% of usual body weight in one month or >10% over a period of six months or longer is considered as severe
  - Other visual signs: loose jewellery, baggy clothes, extra notch in belt, prominent bony features
  ✔ At risk of undernutrition?
  - Mini-Nutritional Assessment Short-Form (MNA-SF): widely used tool to assess nutritional status for older adults
  - Actions:

  • Normal nutritional status (12-14 points): rescreen after an acute event or illness / once per year in community / every 3 months in institutions
  • At risk of malnutrition (8-11 points): no weight loss ➡ close weight monitoring, rescreen every 3 months; weight loss ➡ refer to dietitian for in-depth nutritional assessment and intervention
  • Malnourished (0-7 points): refer to dietitian for in-depth nutritional assessment and intervention

• Strategies to ensure adequate energy intake:

  - Encourage three meals regularly + snacks in between meals
  - Allow enough time for older adults to eat, offer encouragement
  - Follow healthy eating plate to achieve balanced diet

---

---

2. Optimal protein intake

• Protein is a major regulator of muscle protein metabolism
• Old muscle ➡ a reduced muscle protein synthesis (anabolic resistance) ➡ requires larger amounts of amino acids to stimulate muscle anabolism
• Higher protein intake ➡ overcome anabolic resistance
• Low protein intake ➡ reductions in muscle protein synthesis
• Older adults need more dietary protein than do younger people (0.8-1.0g / kg BW / day)
• PROT-AGE Study Group: 1.0-1.2g / kg BW / day for healthy older adults to maintain physical function and muscle mass
• Older adults with severe kidney disease (GFR<30 mL/min/1.73m²) who are not on dialysis are an exception to the high-protein rule; should consult healthcare professionals

Protein-rich diet - 1 serving of protein food contains around 7g protein = 1 tael (兩) of cooked skinless poultry, lean beef, pork and fish (=size of 1 table tennis ball or 1 Mahjong 打牌用的麻雀般大小) = 1 whole egg = 1 / 3 piece of hard tofu = 4 tablespoons cooked legumes = 1 cup of cooked quinoa = 1 cup of milk / calcium-fortified soy milk (240ml) = 30g nuts (1 handful) - Wholegrains ➡ refined grains e.g. 1 bowl of brown rice (6g protein) vs. 1 bowl of white rice (4g protein) Consider a spread feeding pattern with at least 25-30g of dietary protein during the main meals (about the size of palm) ➡ better than a single high-protein meal

---

---

• Examples to increase protein intake:

  Breakfast:
  oats with plain water ➡ oats with milk and eggs
  Plain rice porridge + steamed rice roll 白粥+豬腸粉 ➡ rice porridge with pork + steamed rice roll with dried prawns 瘦肉粥+蝦米腸
  
  Lunch:
  choi sum with rice noodle in soup ➡ choi sum shredded pork with rice noodle in soup
  Steamed chicken feet + custard bun 蒸鳳爪+奶皇包 ➡ steamed dace fish ball,
  chicken bun and boiled vegetable 蒸鯪魚球, 雞包仔, 烚菜
  
  Dinner:
  stir fry tri-colored capsicum, steamed pork rib, white rice ➡ stir fry tri-colored capsicum, steamed salmon, white rice with quinoa
  
  Snacks:
  plain roll 豬仔包 ➡ tuna whole grain sandwich
  Biscuit ➡ plain mixed nuts 無鹽非油炸果仁
  Chinese dessert e.g. soybean curd dessert, sesame dessert, mixed bean soup 喳咋

---

3. Vitamin D

• No specific intervention studies of the effect of vitamin D supplementation on prevention of physical frailty
• No specific guidelines are available regarding the optimal status of 25OHD and recommended dose of vitamin D supplementation to prevent frailty
• Evidence shows positive effect of daily doses of 800 IU or more on muscle strength and balance
• Recommended intake: 15 µg / 600 IU (≤70y); 20 µg / 800 IU (>70y)
• Sources: mostly from sunlight exposure (suggest 15-20 minutes per day)
• Food sources: egg yolk, oily fish (salmon, mackerel, tuna), portobello, fortified food such as milk, soymilk and breakfast cereals

---

4. Omega-3 fatty acid

• Anti-inflammatory properties
• Growing evidence for the beneficial effect of omega-3 supplementation - increase in muscle mass & improve in physical performance for the older adults, especially when > 2g / day of omega-3 and more than 6 months
• Exact dosage, frequency and use (alone or combined) in the treatment and prevention of sarcopenia / physical frailty still need further exploration
• General guideline: 2 servings (total ~240g) oily fish per week

---

5. Mediterranean diet

• Rich in vegetables, legumes, fruits, nuts, whole grains, olive oil; moderate intake of fish and seafood, poultry, eggs, dairy; rare intake of red meat, processed meat, and sweets
• Older adults with higher adherence to MedDiet were less likely to develop frailty and functional disability
• Evidence supports that high adherence to MedDiet reduces the risk of cognitive decline in non-demented older adults (beneficial to the cognitive aspect of frailty)
• Examples to incorporate MedDiet in HK food culture:
  Green leafy vegetable ➡ 2-3 vegetables of different color per meal
  White rice / bread ➡ make at least half the grains as whole grains e.g. add brown rice, quinoa, oats, barley, buckwheat, millet; wholegrain bread and pasta
  Cake / egg tart ➡ fruits or yoghurt as snacks
  Cracker ➡ nuts as snacks
  Chinese restaurant: Steamed chicken feet/ pork rib ➡ steamed dace fish ball (fish or seafood twice a week)

---

B. Reversing sarcopenia/physical frailty with nutrition

• Poor nutrition is related to the occurrence and deterioration of physical frailty
• Nutrition intervention as part of the management plan + collaboration with multidisciplinary teams involving geriatricians, physiotherapists, exercise physiologists, social workers, and occupational therapists, caregivers and the patients themselves

---

1. Maintain a desirable body weight

• BMI for Asian older adults

  - Older adults with higher body weight seem to be beneficial for those who are frail with or without chronic diseases
  - No specific guideline; Normal BMI: 18.5-22.9 for adults ➡ 23.0-24.9 for older adults
  - <23 is considered as underweight for older adults vs. <18.5 for adults
  - If overweight / obese, any advice on weight loss should be carefully considered, as intentional weight loss is accompanied by muscle and bone loss

• Energy requirement: ESPEN recommends 30 kcal / kg body weight/day for older adults, adjusted for gender, nutritional status, disease state and physical activity
• Examine treatable causes of unintentional weight loss

  - MEALS-ON-WHEELS mnemonic

  
  

  

• Strategies to ensure adequate energy intake

  - Encourage three meals regularly + snacks in between meals
  - Allow enough time for older adults to eat, offer encouragement
  - Follow healthy eating plate to achieve balanced diet
  - How to deal with loss of appetite / early satiety?

  • consider size, timing and frequency of meals (small frequent meals rather than large plates of food)

  7:00am	Breakfast
  10:00am	Morning tea
  12:30pm	Lunch
  3:00pm	Afternoon tea
  6:00pm	Dinner
  8:00pm	Supper

  
  • nutritious snacks (every mouthful count)
  • avoid fluid (e.g. soup, water, tea) before and during meals
  • eat meat / vegetable and rice first ➡ then soup
  • use natural seasoning to enhance the flavor e.g. ginger, garlic, onion, mushroom, herbs…
  • changes to enhance mealtime experience e.g. music, presentation of food (colorful), increase food variety
  • engage family carers as part of the nutrition care team
  • "social facilitation": tend to eat more when dining with others rather than alone
  • try to be more physically active to stimulate appetite and help digestion

---

2. Optimal protein intake

• Recommendations from PROT-AGE Study Group:

  - 1.2-1.5g / kg body weight / day for older adults who are malnourished or at risk of developing further comorbidities
  - 2.0g / kg BW / day for older adults with severe illness, injury or marked malnutrition
  - Older adults with severe kidney disease (GFR<30 mL / min / 1.73m²) who are not on dialysis are an exception to the high-protein rule; should consult healthcare professionals

• Protein-rich diet

  - Refer to previous section re: protein sources
  - Protein quality

  - some studies showed beneficial effects of animal protein than plant protein on frailty outcomes
  - animal-based protein has a higher content of branched-chain amino acids (particularly leucine) ➡ eliciting higher muscle protein synthesis compared with plant- based protein
  - animal foods are the primary source of high quality protein, therefore, be the preferred source for frail older adults

• Protein-energy / protein supplementation

  - Shown to increase physical performance and strength (gait / leg strength)
  - Consider when frail older adults report weight loss or undernutrition is diagnosed
  - Paired with a physical activity program to have an additive effect

---

3. Vitamin D

• Insufficient evidence to recommend a vitamin D supplementation regime to treat sarcopenia / physical frailty
• Supplementation in frail older adults has shown positive results in preventing falls
• No consensus regarding the optimal status of 25OHD and recommended dose of vitamin D supplementation to treat frailty
• Supplementation is not recommended for the treatment of sarcopenia / physical frailty unless vitamin D deficiency is present
• According to some scientific societies, a dose of 800-2000 IU per day should be given to frail elderly to reach the recommended minimal serum 25OHD level of (75 nmol / l)
• Clinicians should use their judgement in prescribing vitamin D supplementation

---

4. Mediterranean diet

Unknown effect for the treatment of already established frailty

---

Protein food FAQs


Considerations in using oral nutritional supplement

---

Case study 1

Mr. Chan 70 years old, 60 kg, 160 cm, 2 times Tai Chi per week, no chronic conditions

• Is Mr. Chan overweight?
• What is his daily protein requirement?
• What is the minimum servings of protein food required to meet his protein requirement?
• Try to plan the protein food by distributing the protein in three meals and snacks

Answer

Please revisit MOOC 5 Demand on your CARE: Nutrition for Seniors, Eat Smart, Live Smart for more information.

---

Reference

---

- End of Chapter 2 -

---

Exercise intervention for frailty and sarcopenia

Structured exercise programme

• increase muscle oxygen content, tolerance, and flexibility
• prevent and decrease muscle atrophy
• increase muscle mass
• enhance muscle strength
• improve pace
• improve quality of life and confidence

➡ Positive effects on physical functioning, cognition, and psychological well-being

---

The Benefits of Physical Activities

For more information about fall prevention,
please refer to Demand on your CARE: Keep Preventable Falls Away from You

---

Multi-components of exercise programme

Aerobic/endurance Resistance/ strength Balance Flexibility Image source from : https://www.research.colostate.edu/no-matter-your-age-its-never-too-late-to-improve-your-fitness/

---

WHO guidelines on physical activity and sedentary behaviour (2020)

For older adults, physical activity can be undertaken as part of: recreation and leisure (play, games, sports or planned exercise) transportation (wheeling, walking and cycling) work household chores in the context of daily occupational, educational, home or community settings

---

Incorporate Physical Activities into Daily Life

---

Recommendation

Older adults: should undertake regular physical activity. Strong recommendation, moderate certainty evidence should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence may increase moderate intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence

---

should also do muscle strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity, on 3 or more days a week, to enhance functional capacity and to prevent falls. Strong recommendation, moderate certainty evidence

Image source from : https://www.who.int/publications/i/item/9789240015128/

---

Physical activity pyramid for older adults

---

Image source from: https://www.elderly.gov.hk/english/healthy_ageing/exe_leisure_travel/
create_your_own_exercise_program.html

---

Ideal heart rate during exercise

The American Heart Association (AHA) advise:

• Your maximum heart rate is about 220 minus your age
• Target heart rate during moderate intensity activities is about 50-70% of maximum heart rate, while during vigorous physical activity it's about 70-85% of maximum

---

Tips for undertaking exercise properly

• No-pain rule: if you feel articular or muscular pain, difficulty breathing, dizziness, a rapid heartbeat, etc. during an exercise, stop immediately.
• Use an adequate area: eliminate any obstacles that may increase a risk of falling. When doing standing up or balance exercises, you can use objects that will make it safer (chairs, bars, tables, etc.).
• Make sure your shoes fit you well: they should have flat soles, be anti-slip and offer good support for your heel.
• Wear comfortable clothing.
• Do not hold your breathing during the exercises. Breathe normally.
• Talk to your doctor if you are not sure if you should do a particular exercise, especially if you have had hip or back surgery.
• Stop exercise and seek medical advice immediately if you are not feeling well during exercise.

---

---

Vivifrail Exercise

• Based on the idea that health in older people should be measured in terms of its function and NOT as a disease
• To maintain a level of functionality that maintains the highest degree of autonomy possible in each case
• Designed for older adults above 70, that promotes the practice of physical exercise to improve strength, gait ability and balance, while frailty and falls are prevented
• Multicomponent exercise programme: Resistance, balance, endurance & coordination training
  
  Reference from: https://vivifrail.com/

---

Vivifrail test

• to determine the most appropriate type of multicomponent physical program regarding the functional capacity and risk of falls of the older adults
• consists of assessing functional capacity through the SPPB test and a battery of 4 measures that allow assessing the risk of falls

For details, please refer to Vivifrail multi-component physical training prescription guide.

---

Image source and reference: https://vivifrail.com/wp-content/uploads/2019/11/VIVIFRAIL-ENG-Interactivo.pdf

---

Type A- Person with disability

---

Type B- Person with frailty

---

Vivifrail exercise: Frail

---

Type C- Person with pre-frail

---

Vivifrail exercise: Pre-frail

---

Type D- Robust person

---

Vivifrail exercise: Robust

---

Vivifrail exercise –
free download mobile App

iPhone: https://apps.apple.com/tw/ app/vivifrail/id1463377040 Android: https://play.google.com/store/ apps/details?id=com.mikelizquierdo. vivifrail&hl=zh_HK&gl=US

---

More exercise videos

Performing Balance and Strengthening Exercise at Home

---

Jockey club age-friendly city project, Jockey Club Institute of Ageing, CUHK
Active Ageing Programme

Elderly health service, Department of health
Stay Active at Home

---

Reference

American Heart Association. (2021). Target heart rates chart. www.heart.org. https://www.heart.org/en/healthy-living/fitness/fitness -basics/target-heart-rates

Casas-Herrero, A., Anton-Rodrigo, I., Zambom-Ferraresi, F., Sáez de Asteasu, M. L., Martinez-Velilla, N., Elexpuru-Estomba, J., Marin-Epelde, I., Ramon-Espinoza, F., Petidier-Torregrosa, R., Sanchez-Sanchez, J. L., Ibañez, B., & Izquierdo, M. (2019). Effect of a multicomponent exercise programme (VIVIFRAIL) on functional capacity in frail community elders with cognitive decline: Study protocol for a randomized multicentre control trial. Trials, 20(1). https://doi.org/10.1186/s13063-019-3426-0

The Government of the Hong Kong Special Administrative Region. (2020). "Create your own exercise programme" - for both elders & caregivers. Elderly Health Service.
https://www.elderly.gov.hk/english/
healthy_ageing/exe_leisure_travel/
create_your_own_exercise_program.html

Izquierdo, M., Zambom-Ferraresi, F., Sáez de Asteasu, M. L., Martínez-Velilla, N., Ramirez-Vélez, R., García-Hermoso, A., Casas-Herrero, A., Sinclair, A., & Rodríguez-Mañas, L. (2021, March 6). VIVIFRAIL: A multi-component physical training program to prevent weakness and falls in people over 70 years [web log]. Retrieved January 26, 2022, from https://blogs.bmj.com/bjsm/2021/03/06/vivifrail-a-multi-component-physical-training-program-to-prevent-weakness-and-falls-in-people-over-70-years/

Theou, O., Stathokostas, L., Roland, K. P., Jakobi, J. M., Patterson, C., Vandervoort, A. A., & Jones, G. R. (2011). The effectiveness of exercise interventions for the management of frailty: A systematic review. Journal of Aging Research, 2011, 1-19. https://doi.org/10.4061/2011/569194

World Health Organization. (2020). WHO guidelines on physical activity and sedentary behaviour. Retrieved from https://www.who.int/publications/i/
item/9789240015128 

---

- End of Chapter 3 -

---