The potential benefits of home-based programs to prevent functional decline in the elderly remain equivocal, although most of the literature to date has focused on the restoration of function in disabled elderly following an acute medical event. Few attempts have been made to evaluate so-called "prehabilitation" strategies aimed at preventing functional decline in elderly persons who have suffered neither acute illness nor injury, but who are physically frail nonetheless. In a randomized clinical trial, Gill et al. sought to explore the effect of a home-based intervention program on the functional decline of physically frail, elderly individuals.
The need for longer than 10 seconds to complete a rapid-gait test, or the inability to rise free-handed from a seated position in a hardback chair were used as the defining criteria for recruiting physically frail persons. A total of 188 participants 75 years and older who met one or both of these criteria were randomly assigned to the intervention or control group. The physical frailty and cognitive status of patients were assessed, as well as the self-reported abilities of patients (on a scale from one to 16) to walk, bathe, dress, rise from a chair, use the toilet, eat and groom. Data were collected at baseline, and then at three, seven and 12 months.
Participants in the intervention group were visited at home by a physical therapist 16 times, on average, over six months. Recommended intervention included the completion of supervised resistance exercises using elastic bands, instruction on safe techniques for facilitating various levels of activity, removal of potentially hazardous obstacles in the home, placement of nonskid mats in the bathroom and kitchen, lighting improvement and repair of walking surfaces, stairwells and railings. The control patients received six home visits by a health educator, during which the promotion of good health was reviewed.
The primary outcome was measured as the change between the baseline score and that at each subsequent assessment session. As a whole, participants in the intervention group experienced less disability than those in the control group. This result was especially true in the moderately frail participants (mean score of 2.7 in the intervention group versus 4.2 in the control group), whereas less discrepancy was manifested in those who were severely frail (5.0 versus 6.3). During the 12-month follow-up period, 14% of the intervention group required admittance to a nursing home, compared to 19% in the control group. The average cost per participant in the intervention group was $1,998 (U.S.). The frequency of adverse events in the intervention group was not greater than that in the control group, indicating the safety of the home-based intervention program.
The data indicate the benefit of home-based "prehabilitation" over educational programs, as demonstrated by a marked reduction in self-reported disability after seven and 12 months. The reason for failure of the severely frail participants to benefit significantly from intervention is unclear. While the cost of the program is relatively moderate, the time investment required of physical therapists is greater than that covered by Medicare in the United States. Conducting a Canadian study would be useful firstly to determine whether home-intervention is of similar benefit in Canada, and secondly, to assess whether this benefit is sufficiently large to warrant the extra burden put on Canadian health care professionals.
Source
- Gill TM, Baker DI, Gottschalk M, et al. A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med 2002;347:1068-74.
