Frailty in Older people: Rehabilitation Treatment Research Examining Separate Settings PLUS. (FORTRESS Plus)

The intervention group from the previously registered FORTRESS (Frailty in Older People Rehabilitation Treatment Research Examining Separate Settings) study will act as a control group for the FORTRESS Plus study. Intervention has been completed for the FORTRESS participants. The 12-month outcome assessments for the FORTRESS study will be complete in January 2024. Results for the FORTRESS project will be available at that time point however data analysis and comparison between FORTRESS and FORTRESS Plus will not occur until both projects have completed the final outcome assessments. Eligibility criteria for FORTRESS Plus will be the same as for FORTRESS. Recruitment will occur from the same wards in the same hospital with patients from the same jurisdiction. There will be an “opt out” approach to the study, automatically including all patients in participating wards over the age of 70 in the FORTRESS Plus study, unless they specifically ask to be excluded (this aligns with FORTRESS study recruitment except the FORTRESS Study also excluded people aged 70-74 inclusive). All frailty interventions are based on the Asia Pacific Clinical Practice Guidelines for the Management of Frailty and therefore are consistent with standard care. Recruitment for FORTRESS Plus will be across 6 months and there will be outcome assessments completed for all participants at 4 months and 12 months from the point of recruitment. The study is anticipated to take 20 months in total. During the acute admission, the study Pharmacist will record the Drug Burden Index (DBI) and any recommendations regarding review or deprescribing for each participant. The study pharmacist will review these medications again at 12 months. During the acute admission, the participant will be seen by the hospital dietician if they have indicated a 5kg or 5% loss of weight over the past 12 months and receive education on protein fortification and supplementation. The participant will also be seen by the ward Geriatrician from the Acute Care of the Elderly Team (ACE) for encouragement of Vitamin D supplementation. This will be a face to face discussion. If the participant is found to be deficient in Vitamin D and they are recommended to take a supplement the recommended dosage is 800 - 1000 IU. A basic Frailty Management Plan will be devised to inform the GP of the recommendations made by these clinicians during the patient’s acute admission. Upon discharge home into the community, the participant will be seen by the FORTRESS Exercise Physiologist. The participants will receive up to 7 weekly visits to their home for supervised exercise by an exercise physiologist who will design an individualised exercise program and encourage adherence to any recommendations made by the hospital dietician or/and pharmacist. The duration of the visits will be tailored to depending on individual need but is anticipated to be 30 to 60 minutes per visits. The initial home visit will occur approximately one week post discharge and be a longer visit closer to 90 minutes due to the baseline physical measures that need to be taken using the SPPB (Short Physical Performance Battery Test). The exercise program will consist of resistance and balance exercises adapted from the Otago handbook. In addition to this, group exercise classes that are frailty-specific or other outpatient group exercises may be arranged by the exercise physiologist if deemed appropriate. Motivational interviewing will be conducted at the first initial home visit and is anticipated to take 20 minutes out of the 90-minute session. This will be used to determine stage of behaviour change, and to set goals specific to the participant to inform the prescription of exercises. The carer or next of kin will be contacted and the participants involvement in the study explained to them. It is important to involve significant others to enhance mood and promote adherence. Adherence will be monitored through an exercise calendar which is provided to each participant and where they will be asked to record the details (duration, which exercises were completed) of their self initiated exercise sessions as well as any group exercise classes they are attending.