Frailty Reduction via Implementation of Exercise, Nutritional support and Deprescribing Project: The FRIEND Project

This study involves the delivery of a multicomponent intervention which aims to reduce frailty in residents of aged care living with Mild Cognitive Impairment or Dementia. FRIEND intervention components: Individualised treatment plan for the reduction of frailty: As part of the study, the research team including the study geriatrician, dietitian, exercise physiologist, and pharmacist will work together with the Clinical Nurse Manager and relevant staff members at TGSH, including the resident’s general practitioner (GP), to design individualised treatment plans for the residents that aim to reduce frailty via the implementation of an exercise, nutritional support and medication review intervention. 1. Exercise component of the FRIEND intervention: Targeted residents will attend two strength and balance exercise training session per week. Sessions will be delivered in a purpose-built gym at TGSH and supervised by an Accredited Exercise Physiologist with a ratio of 1:1 to 1:3 depending on level of cognition and function. Session duration will be approximately 60 minutes. Specific resistance exercises critical for mobility and function will include leg press, knee extension, hip abduction, triceps, seated row, and chest press. Additional balance exercises will also be prescribed which include variations of static standing positions (tandem, semi-tandem) and dynamic balance (tandem walking within parallel bars). Intensity will be monitored via participant and assessor-rated ratings of perceived exertion (RPE) and will increase over the first 2 weeks to about 80% of peak capacity, and continuous progression will ensure intensity remains high throughout the intervention period. 2. Nutritional component of the FRIEND intervention: Targeted residents will undergo a detailed assessment of their nutritional status and receive individualised nutritional support. This assessment will involve the completion (with assistance if necessary) of the Mini-nutritional assessment, along with a review of dietary intake and practices by liaising with facility food preparation staff and logs. The nutritional support includes the removal of unnecessary or potentially harmful dietary restrictions that may increase the risk of unintentional weight loss or increase the risk of malnutrition. The research team (including an nutritionist) will review the food/nutrient-drug interactions and exercise-diet interactions and advise the GP when possible, on the potential deprescription or dose reduction of any medication known to cause sedation, constipation, nausea, vomiting, anorexia, and/or diarrhoea. Supplementation of vitamin D will also be included in the nutrition support were indicated after assessment by the participant’s treating GP. Toincrease protein intake and enhance skeletal muscle synthesis a high protein snack will be provided after the exercise sessions and potentially at other times if needed. Nutritional recommendations will be made to the staff and family of residents with malnutrition to increase nutrient density and improve nutritional status. To increase appetite, when possible, exercise will be performed 1 hour prior to a meal to stimulate appetite, and/or walking for at least 5-10 minutes before meals when possible will be encouraged. Enhancement of the aesthetic aspects of food preparation and service and increased mealtime socialisation will be used to promote dietary intake. All of these changes will occur through collaboration with the facility and food preparation staff, who will implement these changes in practice with the consent of the individual. 3. Medication review: A complete drug audit will be carried out at baseline and monthly intervals. This information will be ascertained by reviewing facility records, liaising with the participant's medical team where necessary for further information, and also through in-person interviewing and assessing the participant (the latter to ascertain symptoms, goals, etc.). Established algorithms will be used to identify excess dosages, drugs without sufficient indication, and potentially inappropriate medications (based on BEERS list, STOPP protocols, anticholinergic burden, etc.). GPs will be sent a summary of recommendations based on these audits, including rationale and suggestions for deprescribing strategies. Particular emphasis will be placed on drugs with adverse effects on cognition, appetite, and mobility. Continuous monitoring for any adverse effects of discontinued or reduced dosages of medications will be undertaken by nursing staff and reported to GPs if necessary. The in-person interview will take place as part of the initial assessment and be no longer than 30 minutes at baseline for each resident participant, with case conferences held each month with the care team and study investigators to review progress. 4. Educational component of the FRIEND intervention: Educational modules for residents and families (face-to-face), as well as pharmacy, nursing, GPs, and other relevant staff (online modules) will be delivered to educate on the role that exercise, nutrition and deprescribing has on reducing frailty and improving resident’s overall health. The education modules will be developed specifically for this study to build a comprehensive understanding of best-practice frailty intervention in aged care. The educational modules for staff will include a general module (completed by all), followed by more specific and detailed modules on nutrition, exercise, and medication optimisation respectively, which will be assigned based on the role of the worker in relation to the participants (i.e. a chef will complete the general module, as well as the nutrition module. Conversely a nurse will complete the general module, plus the three specific modules due to their holistic role with the participants). Modules will consist of recorded lecture content (screen of presentation + talking head) specifically developed and adapted for the target audience presented in discrete chunks to improve engagement. Accompanying this lecture content will be instructional videos (when appropriate, such as 'how to' for performing various exercises), simple fact sheets summarising content, and a more comprehensive procedural document (for staff performing the various aspects of the intervention). All of these content will be accessed via a dedicated, encrypted website which securely links to the Redcap database. The general module is expected to take around an hour, while each specific module around 2-3 hours. A knowledge quiz will be completed prior to undertaking the modules, immediately after taking the modules, and then at the completion of the 6-month intervention. Caregivers participants will also complete quizzes (adapted for lay audience) pre and post module delivery, and after 6 months, however will only complete a general module which has specifically adapted for a lay audience. This module will last 1-2 hours. Resident participants will receive a simplified knowledge quiz before and after the delivery of a face-to-face resident talk delivered by the study intervention team lasting for 30-60mins. All of the education modules will take place at baseline prior to the commencement of the 6-month nutrition, exercise and deprescribing intervention over a two week period. Adherence and fidelity to both the educational modules and intervention components will be monitored via online completion of activities (education modules), and via routine data entry throughout the 6-month evaluation period (clinical case notes, dosage reports, redcap data entry, monthly case conference information).