Optimising ageing: Think about frailty, exercise, habitual activity

I have been reviewing some conversations I had with the physiotherapists at their recent conference. They were surprised I wasn’t a physio, and I was very happy with the honorary physio-for-a-day title they gave me. Anyway, here are some thoughts on optimising ageing.

Of course, your older patients are sometimes your favourites, sometimes your nemeses. Living at home is great, but as one ages, sometimes that gets difficult. There seems to be a trend for everyone to downsize, go into retirement villages or move hundreds of miles away to a new place that is cheaper, near children, with more sunshine, or just for the hell of it.

So, here are some things to think about the next time you see one of your older patients.

Frailty is a clinical syndrome that might not be very obvious to the untrained and non-inquiring eye.

Figure 1 shows the imagined line in the sand for functional abilities – that of having enough function to look after yourself in your own home (with or without support) – and two hypothetical people trucking along (shown by the green line higher up and the red line lower down). Then there is a “perturbation”, such as a urinary tract infection, and you can see the red line (person) dipping down below the line of independence before recovering to a slightly lower base level. The green line above has a relatively small dip and recovers to the same level as before the perturbation. The green line represents an older person who is not frail, and the red line is frail – vulnerable to worsening health status from minor illnesses.

Obviously, how you recognise frailty is another story. You may look at physical ability – slowness, weakness, low physical activity, exhaustion and unintentional weight loss are the five criteria of the Fried frailty phenotype.

An accumulation of many deficits is the Rockwood model that was developed from the interRAI comprehensive assessment. The Rockwood Index can be constructed from usual data considering as many items as you have available (it has to be more than 30 items across functional assessments, blood tests, conditions, etc). If you have 30 items, those with deficits in more than 20 per cent of them are said to be frail.

GPs tend to recognise frailty with a “gut feeling”. For example, you might think that your patient will do badly after their knee replacement or if they were to fall. What is needed, of course, is some prehabilitative action – some encouragement and a check over, looking for underlying anaemia, inactivity and misery.

Treatments for frailty can be reactive or preventive, and nutrition and exercise tend to be the most common. You might say, “Eat more protein, especially in the morning, and exercise please.” Or, if you are more into motivational interviewing, you can ask, “How could you manage to do a little more activity?”

Exercise, particularly progressive resistance training in the formally supervised, thrice-weekly, vigorous form is effective in delaying and reversing frailty. However, it is not consistent and also very hard to “enforce” in those aged 70 and over.

General habitual activity is good too and is associated with less frailty (it’s a chicken or egg scenario, but exercise can be influenced more easily than frailty). Those who live in houses with stairs live five years longer. The biggest differential is between the very sedentary and those with any activity, and it is a dose response where more is better.

Figure 2 is from my PhD in Australia in the 1990s. I think it still applies, especially when I talk with older patients living in the family home. The figure shows the activity patterns of 276 people over age 65 living in Melbourne suburbs. Activity (minutes per two weeks) was self-reported and categorised into walking, gardening, sports (mostly bowls, golf and swimming), housework and home maintenance, and other. I never published these data, so you are the first official audience.

It is not rocket science to see that, overall, men outstrip women in activity levels in everything except housework. The main point is that housework makes up almost half of older women’s activity, and I postulate that in this setting, housework is life-saving! I was giving this talk one day and my husband in the audience piped up and said, “So, when are you going to start?” Hmmm.

Now, let’s imagine what happens when that little old lady moves into a unit – what happens to her access to housework activity? It must be replaced by other activity on a regular daily basis. How to do that in the new environment is a very important question you can ask.

Social connections, activities and interactions are also life-saving. Vibrant social networks are associated with better activity levels, longer life, fewer adverse events and pretty much most positive outcomes.

I met a woman walking in a South Island city, and she told me her tale of moving across town because a unit was available there (not locally) after her husband died. The trouble was, her bridge partner and reading buddies were now across town, and she had trouble getting back for the weekly activities. The folk in the new place weren’t friendly, and she had never been so lonely.

So, what happens when a patient’s move is further and the oomph needed to create new social connections has faded? Talking with older people about these things can edge into your regular conversations, as well as talking through other complex family matters. Perhaps, it is part of the life coach role that the GP has – after all, the longer you stay in the one place, the more events go by to talk about, such is the flavour of continuity.

So, to optimise ageing, think about frailty, take habitual activity like a daily therapy, and hang out with your favourite people. That’s my column for this month.

Next will be equity in aged care and how we are heading for a crisis of bed availability and inability to pay! But that’s another story, and it might be better to avoid it as we head for the holiday season. Perhaps getting fish hooks out of fingers and what to pack for holiday is a better topic.

Ngaire Kerse is a professor of general practice and primary health care, and the Joyce Cook Chair in Ageing Well, University of Aucland