K.F. Boreskie1,2,3, J.L. Hay1,2, T.A. Duhamel1,2
1. Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada; 2. Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Center, Winnipeg, Manitoba, Canada; 3. Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
Corresponding author: Kevin F. Boreskie, St. Boniface General Hospital Albrechtsen Research Center, R4012-351 Tache Ave, Winnipeg, MB, R2H 2A6, Canada, Email: kboreskie@gmail.com, Twitter: @kboreskie
J Frailty Aging 2020;9(3)130-131
Published online June 6, 2020, http://dx.doi.org/10.14283/jfa.2020.29
Key words: Coronavirus disease 2019 (COVID-19), SARS-CoV-2, frailty, prevention.
High rates of SARS-CoV-2 infection and mortality in long term care (LTC) facilities epitomize the contextual and biological risk of those frail and vulnerable among us (1). Much ado has been given to the vulnerability of older adults during the COVID-19 pandemic, but this vulnerability likely has much more to do with the reduced physiological resilience inherent to frailty status rather than chronological age per se (2). While strict measures to protect those who are frail are warranted, without careful consideration, these strategies will lead many older adults out of the frying pan and into the fire. The harsh reality is many at-risk adults will face disproportionate social isolation, depression, malnutrition, reduced access to care, decreased physical activity, and increased sedentary time as a result of infection prevention measures. Therefore, even frail adults who do not contract COVID-19, will undoubtedly experience reduced quality of life, accelerated frailty progression and worse clinical outcomes (3, 4).
Recent commentaries have highlighted the potential health crises the pandemic restrictions may exacerbate in older adults. Lippi et al. discuss the increased risk for cardiovascular disease as a result of social distancing induced physical inactivity (5). Brooke et al. explore strategies to overcome the negative impact of isolation (6), and Jimenez Pavon et al. suggest mitigating aging and disease progression by increasing the frequency and duration of physical activity (7). Holistic health maintenance to address frailty during the pandemic requires an amalgamation of these approaches. For example, increasing physical activity has numerous benefits; however, physical activity is only part of the picture and adding proper nutrition could potentiate these benefits. As frailty is characterized by physiological declines across a variety of systems, interventions and recommendations to slow its progression should also come in the form of broad-based approaches. Given the uncertainty surrounding the length of time infection prevention measures will be in place, it is essential to empower at-risk adults and their caregivers with strategies known to slow the progression of frailty while still mitigating COVID-19 exposure risk.
Focusing on accepted general health interventions specifically for frailty from consensus statements (8, 9) and adapting these to the current pandemic scenario will be critical for maintaining the health of our pre-frail and frail population regardless of SARS-CoV-2 infection. We have summarized consensus recommendations relevant during the COVID-19 pandemic in a figure to help SAVE frail older adults from frailty progression and health declines (Figure 1).
Figure 1
SAVE model for preventing frailty progression
Socialization
There is increasing recognition of the health benefits associated with socialization and interaction in older adults (10). Social distancing precautions will mean that these interactions, along with cognitive stimulation, will likely have to be overcome through technology such as social media and telephone or video calls. Making efforts to provide older frail adults with technology to use social media platforms and adequate instruction on their use is critical.
Adequate Nutrition & Protein Supplementation
Maintaining adequate nutrition is vital in order to prevent malnutrition (defined as an unintentional, nutritional intake imbalance but not necessarily a decreased intake) (11) – a known risk factor associated with frailty (12). Malnutrition can lead to loss of lean muscle mass (sarcopenia) and muscle function (dynapenia) with aging (13, 14). As such, strategies to support adequate nutrition is a potentially modifiable factor that can support health in adults with vulnerability due to frailty. For example, evidence-based recommendations for optimal dietary protein intake in older people recommend that frail older adults consume at least 1.2-1.5 grams of protein per kg body weight per day can help to preserve muscle mass and physical function (15).
Vitamin D
In older populations with vitamin D deficiency, supplementation of vitamin D has been suggested as a means of reducing adverse outcomes (8). While few trials have directly examined the effect of Vitamin D intervention on frailty status, cross-sectional studies in older adults have demonstrated improvements in physical performance (16). Spending increased time indoors during the COVID-19 pandemic could exacerbate Vitamin D deficiency in older adults. Trying to incorporate outdoor time while safely being exposed to the sun and/or supplementing the diet with Vitamin D in those who are deficient may ameliorate some declines in health during the pandemic. Outdoor time while maintaining social distancing precautions would also promote reduced sedentary time while providing psychological benefits (17).
Exercise, Physical Activity & Reduced Sedentary Time
Exercise recommendations for pre-frail and frail older adults include multi-component exercise with an emphasis on resistance training supplemented by aerobic exercise with balance and flexibility work (18). Although the optimal dose of physical activity is uncertain for frail adults, international physical activity guidelines for older adults recommend trying to achieve 150 minutes of moderate-vigorous aerobic physical activity with strength training on at least two days per week (19). To make activities as accessible as possible, older frail adults should be provided with instruction on simple, bodyweight exercises such as chair stands or chair exercises, and can incorporate lifting household items in a safe manner. In addition, small goals to increase steps per day can be achieved through pedometers or phone apps to increase motivation (20).
As devoted exercise time may become increasingly unrealistic to achieve during the pandemic, a greater emphasis should also be placed on reducing sedentary time to mitigate frailty progression. Sedentary behaviors lead to frailty deterioration under normal circumstances (21). With individuals sheltering in place it must be stressed that physical activity of any duration will positively impact overall health across multiple systems (22).
Disseminating recommendations to maintain the health of these pre-frail and frail older adults despite the current obstacles will require creative thinking and a concerted effort, especially as frail adults will likely be the last to reintegrate from social distancing approaches (23). While it is essential to keep frail populations free from SARS-CoV-2 infection risk, keeping health maintenance efforts in mind will be critical for not only for frail adults, but the population as a whole. Otherwise, we may see continued healthcare stress even as we exit the pandemic secondary to the measures meant to keep those at risk safe. The future does not have to be frail; rather, we can implement strategies to help SAVE frail older adults from frailty progression and health declines.
Conflicts of Interest: None declared by the Authors.
References
1. McMichael TM, Currie DW, Clark S, et al. Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington. N Engl J Med 2020
2. Boreskie KF, Boreskie PE, Melady D. Age is just a number – and so is frailty: Strategies to inform resource allocation during the COVID-19 pandemic. CJEM 2020;1–5
3. Steinman MA, Perry L, Perissinotto CM. Meeting the Care Needs of Older Adults Isolated at Home During the COVID-19 Pandemic. JAMA Intern Med 2020
4. Aprahamian I, Cesari M. Geriatric Syndromes and SARS-COV-2: More than Just Being Old. J Frailty Aging 2020
5. Lippi G, Henry BM, Sanchis-Gomar F. Physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (COVID-19). Eur J Prev Cardiol 2020;2047487320916823
6. Brooke J, Jackson D. Older people and COVID-19: Isolation, risk and ageism. Journal of Clinical Nursing ;n/a
7. Jiménez-Pavón D, Carbonell-Baeza A, Lavie CJ. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: Special focus in older people. Prog Cardiovasc Dis 2020
8. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc 2013;14:392–397
9. AVOID Frailty. Canadian Frailty Network
10. Evans IEM, Martyr A, Collins R, Brayne C, Clare L. Social Isolation and Cognitive Function in Later Life: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2019;70:S119–S144
11. Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition – An ESPEN Consensus Statement. Clin Nutr 2015;34:335–340
12. Ligthart-Melis GC, Luiking YC, Kakourou A, Cederholm T, Maier AB, de van der Schueren MAE. Frailty, Sarcopenia, and Malnutrition Frequently (Co-)occur in Hospitalized Older Adults: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2020
13. Genton L, Karsegard VL, Chevalley T, Kossovsky MP, Darmon P, Pichard C. Body composition changes over 9 years in healthy elderly subjects and impact of physical activity. Clin Nutr 2011;30:436–442
14. Broadwin J, Goodman-Gruen D, Slymen D. Ability of fat and fat-free mass percentages to predict functional disability in older men and women. J Am Geriatr Soc 2001;49:1641–1645
15. Bauer J, Biolo G, Cederholm T, 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;14:542–559
16. Ju SY, Lee JY, Kim DH. Low 25-hydroxyvitamin D levels and the risk of frailty syndrome: a systematic review and dose-response meta-analysis. BMC Geriatr 2018;18
17. Lahart I, Darcy P, Gidlow C, Calogiuri G. The Effects of Green Exercise on Physical and Mental Wellbeing: A Systematic Review. Int J Environ Res Public Health 2019;16
18. Jadczak AD, Makwana N, Luscombe-Marsh N, Visvanathan R, Schultz TJ. Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews. JBI Database System Rev Implement Rep 2018;16:752–775
19. World Health Organization. Physical activity. https://www.who.int/news-room/fact-sheets/detail/physical-activity. Accessed 27 Apr 2020
20. Dasgupta K, Rosenberg E, Joseph L, et al. Physician step prescription and monitoring to improve ARTERial health (SMARTER): A randomized controlled trial in patients with type 2 diabetes and hypertension. Diabetes Obes Metab 2017;19:695–704
21. Kehler DS, Hay JL, Stammers AN, et al. A systematic review of the association between sedentary behaviors with frailty. Exp Gerontol 2018;114:1–12
22. Jakicic JM, Kraus WE, Powell KE, et al. Association between Bout Duration of Physical Activity and Health: Systematic Review. Med Sci Sports Exerc 2019;51:1213–1219
23. Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science 2020