Individualized therapy for elderly patients using exercise and nutrition to reduce dependence post discharge trial

A prior qualitative study of frail and pre-frail hospitalised older adults (n=22) was conducted at the research site to inform the intervention protocol. Intervention participants will receive a community extended individualised nutrition and exercise care plan that spans 3-months post discharge. They will receive both nutrition and exercise intervention during admission. After discharged, they will be supported through an ambulatory service in the form of home visits and telephone calls. Nutrition therapy – The FMC dietitian will formulate an individualised nutrition care plan tailored to their medical conditions, nutritional requirements and food preferences, which will be provided while patient is admitted. The medical nutrition therapy (MNT) will aim at providing 100 per cent of their energy and protein requirements to achieve ideal body weight, estimated from the Harris Benedict equation used in acute setting (Roza & Shizgal 1984). Medical nutrition therapy provided can include the use of commercial oral nutrition supplements (selected within hospital’s inpatient formulary where costs are covered), mid-meal snacks (limited to hospital’s food service menu) and food fortification strategies, catered to the individual patient’s preferences and tolerance. Optimal care in terms of frequency of reviews and input will be left to the discretion of the dietitian as individualised therapy will vary between patients. The dietitian will suggest a multivitamin/mineral if deemed necessary, but prescription will be left to the discretion of treating clinicians. Dietetic counselling, with an aim to augment energy and protein intake, will be provided to patients and their caregivers prior to discharge to ensure continuity of the nutritional care plan at home. If patient is not seen by the ward dietitian, he/she will be assessed at the initial home visit. If the patient is to be discharged to a nursing home, the recommended nutritional care plan will be forwarded to the respective care managers. Results from the qualitative study also informed that diet intervention to involve meeting the recommendations of food groups and hydration in the Australian Guide to Healthy Eating (AGHE). Protein intake was a key in the previously described diet intervention. The research team decided to set a specific recommendation for protein intake (1-1.2g/kg body weight/d) to maintain and regain lean body mass based on guidelines (Bauer et al 2013). Exercise therapy – In addition to any usual physiotherapy care, patients will also receive a daily supervised chair stand and heel-raise exercise-training program that is individualised to their physical capacity, adapted from the STAND-Cph trial (Pedersen et al. 2016). Following a warmup, patients will complete the chair stand and heel raise exercises, supervised by an allied health assistant or professional. Exercise progression is individually determined, and each inpatient session will last 10-15 minutes. Program oversight will be provided by each patients’ treating physiotherapist and patients will be assisted to self-regulation by monitoring perceived exertion, ensuring safe program delivery. In the first part of the exercise program, patient will be asked to sit in a hospital chair with arm rest and approximately 45cm seat height. The back of the chair will be placed against a wall to prevent it from sliding during exercise. The patient will then be asked to rise to a fully extended position and sit down at a constant rate. They will be verbally encouraged by the exercise- allied health assistant or professional to perform as many as possible to ensure training to failure of muscle contraction during the initial visit. Should the patient be able to perform more than 12 reps without assistance, he/she will progress to the next level, performing the exercise while wearing the weighted vest (1-9kg), to reach 8-12 RM and so forth. If the patient is unable to perform eight repetitions at standard level, they are permitted to regress to below standard level, allowing them to use the armrest in the concentric phase, and so on. Patients will be asked to repeat the three set of 12 reps, with a 2-min pause allowed between sets. The Borg rate of perceived exertion scale will help guide the allied health assistant or professional in progression or regression of the exercise intensity. In the second part of the exercise program, patient will be asked to position the chair such that the chair faces the wall to prevent it from sliding during exercise. The patient will be asked to stand behind a chair for balance support. Before beginning, they will be asked to keep the feet on the floor at shoulder width. They will then be directed to lift both heels to stand on their forefeet and lower their heels to a standing position at a constant pace. During training, allied health assistant or professional will verbally encourage the patient to perform as many repetitions as possible, maintaining the same pace to ensure training to contraction failure. Should the patient be able to perform more than 12 reps without assistance, he/she will progress to the next level, performing the exercise while wearing the weighted vest (1-9kg), to reach 8-12 repetition max (RM) and so forth. Similarly, the Borg rate of perceived exertion scale will help guide the allied health assistant or professional in progression or regression of the exercise intensity. As informed by a prior qualitative study of frail and pre-frail hospitalised older adults (n=22) conducted, walking will be added to inpatient exercise session daily. Patient will be given a chance and encouraged to walk for 10 minutes, or as tolerated based on individual tolerance, with the allied health assistant to ensure safety. Inpatient exercise session will last approximately 20 minutes, inclusive of walking time. Before and upon completion of the exercise, patients will also self-rate the degree of muscle soreness from previous rep on the numerical rating scale (NRS) from 0 to 10 (no pain to worst possible pain) upon completion of a level (Bergh et al 2000). Patients will only proceed if they have pain score or less than 5. Community therapy and follow-up – After discharge, patients will be provided with an ambulatory nutrition-exercise service (4 home visits and 4 telephone calls within 3 months). This is to ensure compliance to both therapies and to troubleshoot related issues i.e. unable to perform dietary modifications. They will be guided by a dietitian with training in exercise supervision to ensure continuity of dietetic care and exercise at home. At the first home visit, patients will be taught strengthening exercises (front knee, back knee, side hip, toe raises, calf raise, sit to stand) from the Otago community exercise program in addition to a refresher of the inpatient exercises (Liu-Ambrose et al 2008). Both set of exercises are to be done 3 times a week, on alternate days, for a period of 3 months post discharge. To sustain engagement, patients will also receive health coaching during the home visits/telephone calls– a one-on-one patient-health provider approach model with motivational interviewing. References Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013;14(8):542-59. Bergh, I., Sjöström, B., Odén, A. and Steen, B., 2000. An application of pain rating scales in geriatric patients. Aging Clinical and Experimental Research, 12(5), pp.380-387. Liu-Ambrose, T., Donaldson, M.G., Ahamed, Y., Graf, P., Cook, W.L., Close, J., Lord, S.R. and Khan, K.M., 2008. Otago home-based strength and balance retraining improves executive functioning in older fallers: a randomized controlled trial. Journal of the American Geriatrics Society, 56(10), pp.1821-1830. Pedersen, M.M., Petersen, J., Beyer, N., Damkjær, L. and Bandholm, T., 2016. Supervised progressive cross-continuum strength training compared with usual care in older medical patients: study protocol for a randomized controlled trial (the STAND-Cph trial). Trials, 17(1), p.176. Roza, A.M. and Shizgal, H.M., 1984. The Harris Benedict equation reevaluated: resting energy requirements and the body cell mass. The American journal of clinical nutrition, 40(1), pp.168-182.