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HOME-BASED EXERCISE PROGRAMS FOR THE OLDEST-OLD TO ATTENUATE PHYSICAL FRAILTY: A SCOPING REVIEW

 

B. da Silva Capanema1, F. Fank1, M.C. Machado Trento1, D. Lima Costa1, A.R. Amaral da Rocha1, G. Zarpellon Mazo1

 

1. Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil.

Corresponding Author: Bruna da Silva Capanema, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil, E-mail: brunacapanema84@gmail.com

J Frailty Aging 2024;in press
Published online May 2, 2024, http://dx.doi.org/10.14283/jfa.2024.41

 


Abstract

BACKGROUND: With the significant increase in the number of long-lived elderly people living at home, the development of effective physical exercise interventions at home becomes essential to preserve their independence and delay institutionalization and hospitalizations.
OBJECTIVE: to map and describe home exercise programs for elderly people aged 80 or over with physical frailty.
METHODS: The scoping review allowed the inclusion of several methodologies and varied perspectives, maintaining rigor in accordance with the methodological steps of the Joanna Briggs Institute (JBI). The systematic search covered studies available until May 2023 in five databases and gray literature. Frailty was assessed according to the criteria of Fried et al. (2001), physical performance scale (SPPB), such as gait and mobility, and the authors’ assessment of reduced physical function were considered. The study followed the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines and is publicly available in the Open Science Framework (OSF) repository.
RESULTS: Twenty studies were identified that met the inclusion criteria. The total number of elderly people investigated in the study was 1,796. The most important physical interventions were muscular strength training, mainly of the lower limbs, together with flexibility, balance, aerobic and functional training. These home interventions have demonstrated potential, safety and effectiveness in preventing and alleviating physical frailty. These home interventions demonstrated potential, safety and effectiveness in preventing and alleviating physical frailty, adherence in most studies varied between 72% and 89%.
CONCLUSION: This study will allow us to design home-based exercise interventions, potentially providing practical solutions and assisting healthcare professionals in home-based interventions to reduce and mitigate physical frailty in the growing population of older adults. It will also help fill the existing knowledge gap and provide recommendations for future research.

Key words: Aged, 80 and over, physical frailty, physical activity, exercise training, home care.


 

Introduction

Population aging is a global trend, a fact that renders this topic pertinent to both the scientific community and those responsible for shaping public policies (1). Of particular note is the segment of older adults, aged 80 or over, that has experienced the most substantial growth in recent decades and is projected to triple by 2050 (2). Consequently, there is a pressing need for specific strategies and actions designed to promote healthy aging of older individuals (3).
Some international studies have shown an increase in the prevalence of frailty in the oldest-old population (4-7). According to the World Health Organization (WHO) (8), frailty is a gradual decline in physiological systems that are related to age, resulting in a decrease in intrinsic capacities (i.e. mental, physical, and psychological capacities), which are crucial for maintaining life. They also require assistance with activities of daily living (ADLs) (9), hospitalization, and death caused by falls (4) Thus, these individuals have a growing need for health and social care (10, 11).
The literature often defines physical frailty as reduced physical capacity due to decreased muscle strength, walking speed, self-reported exhaustion, involuntary weight loss, and low levels of physical activity (5, 12, 13). A person is considered frail if they have at least three of the five characteristics; pre-frail if they have one or two characteristics; and robust if they have none of the characteristics (12). This syndrome is strongly associated with sarcopenia (loss of function and muscle mass) induced by biological ageing (14), which puts older people at particular risk of disability (15).
Numerous reviews and position statements have confirmed the benefits of physical activity and exercise in preventing and delaying the onset of physical frailty (12, 18, 19). For individuals already suffering from frailty, regular physical exercise plays a key role in preventing muscle atrophy and weakness, improving cardiorespiratory and cognitive capacity, improving metabolic health (6, 20), and improving walking ability and balance. This leads to better mobility (21), greater independence, a lower risk of falls (8) and consequently better performance in activities of daily living (22).
However, despite the positive effects of physical training, the literature indicates that adherence to regular physical activity among oldest-old individuals is low (20, 23). This situation arises from barriers to physical activity perceived by this group. These barriers include the need for transportation assistance (17), since older people often rely on family members or caregivers to leave their homes (16), and a sense of insecurity when moving attributed to the precarious conditions of public roads, which contributes to fear of falls (18). Furthermore, a review found that the majority of this population prefer to remain in their own homes and communities for physical activity (19).
Within this context, home-based physical exercise programs can play a significant role in increasing participation, particularly among frail older individuals (20). A meta-analysis revealed that older adults who engaged in physical exercise at home exhibited a low dropout rate from the program (13.5%), with substantial improvements in activities of daily living (ADLs) (17). Furthermore, home-based exercise programs have the potential to reduce adverse health risks for frail older adults (23, 24). These individuals, due to their physical limitations, are already socially isolated (25). Therefore, the advantages of exercise can assist in reintegrating this population into the social environment (26).
In this way, this scoping review can be used to map the literature in terms of nature, characteristics, and volume; clarify definitions and conceptual limits; and identify gaps and research recommendations that address home exercise programs for oldest-old with physical frailty. Research also underscores the need for adapting physical training programs to frail older adults (27) and for using home exercise protocols tailored to the degree of physical frailty (16). Therefore, scoping studies seeking to answer the following guiding questions are important: 1) What is the existing knowledge about the effectiveness of home-based exercise programs for older people with physical frailty in terms of physical fitness and functional capacity? 2) What is the scope of the methods used in home-based physical exercise programs to reverse and/or alleviate physical frailty in oldest-old people? 3) Which specific knowledge gaps related to home-based exercise programs for older individuals with physical frailty warrant further investigation?
Therefore, this study aims to map and describe home-based exercise programs for older adults aged 80 and over with physical frailty. The findings of this study will enable us to outline home-based exercise interventions, potentially providing a practical solution to reduce and mitigate physical frailty in the growing population of What is the scope of the methods used in home-based physical exercise programs to reverse and/or alleviate physical frailty in oldest-old people? Additionally, the increasing need of this population for home care (24) can help counteract the rise in sedentary behavior and physical inactivity, both of which are associated with physical frailty (28). Research on this topic is also important since it will assist healthcare professionals in home-based exercise interventions for older people with frailty. This study will not only help fill the existing knowledge gap but also provide recommendations for further investigations.

 

Methods

Study design

This scoping review was conducted following the methodological steps outlined by the Joanna Briggs Institute (JBI) (29, 30). This scoping review technique is being widely used around health sciences to synthesize and disseminate the results of studies on a subject (29, 30).Thus, aiming to map, through a rigorous and transparent method, the state of the art in a thematic area, intending to provide a descriptive view of the studies reviewed, also clarifying definitions and conceptual limits; identify gaps and recommend research, and also summarize the results of studies with different methodologies without critically evaluating them or summarizing evidence from different investigations, as occurs in a systematic review (29, 30, 31). Additionally, the review followed the PRISMA Extension for Scoping Reviews (PRISMA-ScR) reporting guidelines (31). Both the study protocol and the research strategy are publicly accessible in the Open Science Framework (OSF) repository (https://osf.io/u94sm/) (32).

Search strategy

In this scoping review, the search strategy was performed in three steps. First, a preliminary search was conducted in multiple databases, including PubMed, CINAHL, SCOPUS, Web of Science, and LILACS. Medical Subject Headings (Mesh) and Health Science Descriptors (DeCs) terms were used, and no language or publication date restrictions were applied. Keywords were combined using the Boolean operators OR and AND, as shown in Table 1. This process involved the analysis of words within the titles and abstracts of selected articles, as well as the indexing terms used to describe these articles. In the second step, an additional search employing the keywords identified in the included studies was conducted.
Next, the reference list of identified reports and articles was thoroughly examined for additional sources. In this third step, the researchers analyzed the reference lists of all identified sources, in addition to the reference lists of the sources that were selected for full-text analysis and/or included in the review. Finally, a gray literature search was carried out to identify difficult-to-locate or unpublished materials (32). When data were missing or unclear, two attempts were made to contact the authors via email to request the necessary data. Studies were excluded when there was no response from the authors. The search for articles was conducted until May 10, 2023.

Study selection and eligibility criteria

The selection of studies included in the scoping review followed a predefined set of inclusion criteria based on the PCC acronym, which stands for population, concept, and context (30) (Table 1). The process of source selection, including both title/abstract and full-text screening, was conducted in pairs by two or more independent reviewers (BSV, FF, MCT, DLC). Disagreements were resolved through consensus or by consulting a fifth reviewer (GZM). All procedures, from initial article selection to full-text assessment, were managed using the Rayyan QCRI® software (33).

Table 1. Study search strategy according to the PCC strategy

Source: Prepared by the author (2023).

 

The eligibility criteria for the studies were: 1) participants had to be 80 years or older; 2) frailty should be assessed using Fried et al. (2001) criteria, physical performance scales (SPPB), performance-based measures such as gait and mobility, or by considering authors’ assessment of reduced physical function; 3) studies should include physical exercise protocols, physical activity at home, or physical assessments carried out at home. Any type of study was eligible for this scoping review.
The exclusion criteria of the studies were: 1) older adults under 80 years of age; 2) studies that focused exclusively on populations with illnesses (such as chronic degenerative diseases, cancer, osteoarticular diseases, fractures, respiratory diseases, COVID-19); 3) studies that did not address physical exercise protocols, home physical activity, or physical assessments carried out at home; 4) studies that involved physical exercise programs in long-term care institutions.

 

Results

A total of 2,463 studies were retrieved from various databases: Web of Science (n=45), Scopus (n=152), PubMed (n=1,917), Lilacs (n=12), and Medline (n=337). After removing 107 duplicates, 2,356 studies remained. Among these, 2,247 were excluded based on titles and abstracts. After reading the abstracts, 109 studies were screened, and an additional 68 studies were excluded. Thus, 41 articles were selected for full-text reading. Searching the list of references and gray literature identified four more articles that had not previously been included. After this process, 20 studies were included in the final analysis of this scoping review. Figure 1 shows the flowchart of the article screening and selection process.

Figure 1. PRISMA-ScR flow diagram

 

Characteristics of the included studies

Twenty studies were included in this review. The characteristics of the studies are described in Table 2. The studies were published between 1995 and 2022. Fifteen of the 20 studies are randomized clinical trials (34–48). Six of these studies included control groups undergoing usual healthcare (34, 36–38, 43, 47). There was also one non-randomized controlled clinical trial (37), two experimental studies (49, 50), and three pilot studies (44, 51, 52).

Table 2. Overview of included studies

Table 2 (continued). Overview of included studies

Table 2 (continued). Overview of included studies

Table 2 (continued). Overview of included studies

Table 2 (continued). Overview of included studies

Table 2 (continued). Overview of included studies

Source: Prepared by the author (2023).Legend: CG= Control Group; EG= Exercise Group; LL= Lower limbs; UL= Upper limbs; OTAGO= Fall Prevention Program; VM = Gait speed; i = interval; HGS= Handgrip strength; PA= physical activity; BMI= body index mass; ADLs= activities of daily living; IADLs = instrumental activities of daily living; rep=repetition

 

Five studies were conducted in the United States (35, 36, 38, 41, 49), three in Norway (39, 40, 44), two in Canada (37, 51), two in Austria (48, 50), two in Spain (45, 46), one in France (43), one in Denmark (42), one in the United Kingdom (34), one in the Netherlands (52), one in Finland (53), and one in Brazil (47). The total number of older adults investigated across the studies was 1,796. Of these, 1,353 (72%) were women and 443 (28%) were men. It is important to note that one study did not report the distribution by sex (34). Additionally, two studies exclusively involved oldest-old women (42, 54).
The sample size was less than 30 oldest-old people in three studies (44, 50, 54), ranged from 40 to 80 participants in seven studies (34, 37, 39, 40, 42, 47, 51) and from 80 to 135 in five studies (35, 41, 43, 45, 48), and included more than 188 oldest-old individuals in five studies (36, 38, 46, 53). Only one study did not report the sample size since it was a pilot project of a home-based exercise protocol (52). Participants were referred to home exercise programs by a public primary care service (35, 37, 44-48, 50), a community service (39-43, 51, 53) and a private service (34).

Home-based physical exercise programs for older adults with physical frailty

Regarding the type of home-based physical exercise program for older adults with physical frailty, all studies implemented interventions based on strength training. Five studies chose progressive loading (50–80%) (41, 45, 51, 53, 54) and five studies applied elastic resistance with progression of elastic band intensity, changing the color of the band (35–38, 42). One study also used resistance exercises with an elastic band, which, however, led to participant exhaustion (24). One study introduced explosive concentric and slow eccentric strength training (44) and seven studies used body weight resistance exercise (34, 35, 40, 45, 47, 50, 51) In contrast, five studies did not specify the training load used (43, 45, 46, 50, 52) and two studies did not perform training progression (39, 40). Regarding the studies that used strength training, the volume ranged from three to five sets and the repetitions from eight to 15. Exercise intensity was evaluated by 1RM test in two studies (41, 49), one of them was evaluated by the Borg subjective effort scale (53), the others were not specified (45, 51).
In addition to strength training, nine studies added balance training (35, 36, 38, 42–46, 52), eight studies included flexibility exercises (34, 35, 37, 41, 42, 51–53), eight interventions consisted of functional exercises (39, 40, 42, 47, 50, 52, 53, 55), seven of aerobic training (37, 39, 40, 42, 45, 46, 50) and four performed functional training (39, 40, 52, 53).
In most studies (n=18), the training programs lasted 2 to 6 months, with the frequency ranging from two to five times a week (24, 34–44, 46, 47, 50–52, 54). Two studies implemented long-term interventions, one study had a duration of 36 months, with three weekly sessions (45), and another study spanned 12 months, with two weekly sessions (53) and no study reported a follow-up. Figure 2 shows a summary of the home-based physical exercise protocols for frail oldest old people in the studies included in this scoping review.

Figure 2. Summary of the home-based physical exercise protocols for frail oldest old people in the studies included in this scoping review

 

In 10 studies, the participants received illustrative leaflets containing physical exercises. Additionally, health professionals (nurses, doctors, and/or physical therapists) visited the participants once a week or every fortnight to monitor the training and for physical assessments (36–40, 42, 43, 46, 47, 51). In two of these studies, the participants were encouraged to exercise through weekly telephone calls (47, 52).
In four studies, sessions were conducted by physical therapists (35, 40, 53, 54). In one study, the initial sessions were conducted by a physical therapist who provided verbal and written instructions. Thereafter, the participants performed the interventions independently or with the assistance of family members (34). In two studies, health professionals conducted the initial sessions. After adaptation, the older adults received instructional materials such as videos (DVD) and/or tablets, which were recorded by health professionals (51, 52). Three articles did not specify the professional responsible for training monitoring but indicated that a qualified trainer was involved (24, 41, 44).
To prove adherence to home physical exercise programs, the participation of oldest-old in the program was recorded. Among these, 12 studies reported high adherence, ranging from 72% to 89% (24, 34, 36–42, 44, 46, 47). We highlight the study by Suikkanen and collaborators (53), in which adherence remained high (75%) even after one year. There was also considerable adherence (67.6%) in the study by Guinea-Huguet et al. (45), which involved a long-term intervention (three years). Among the other studies included, only two achieved average adherence (below 50%-60%) (43, 54). One study reported high adherence but did not specify the percentage (50), two studies did not provide information on adherence (35, 51), and one study did not perform the experiment (52). It is important to note that adherence to home interventions in the included studies was monitored in different ways, such as weekly phone calls, face-to-face visits, the use of movement sensors by participants and self-report diaries.
The most common physical assessments used in the studies included in this review were the timed up and go test (TUG) (34, 37, 39, 40, 45–47, 50–52), measurement of handgrip strength (HGS)(24, 34, 35, 39, 42, 44, 47, 52, 53) and gait speed (35, 38–40, 42–44, 47, 54), evaluation of body composition (24, 42–44, 47, 52, 53), the sit-stand test (34, 37, 42, 44, 45, 52, 54), physical performance tests (24, 35, 41, 42, 53), physical activity level scales (43, 44, 50, 52), accelerometers (47, 52), treadmill exercise tests (35, 41) and the 1 repetition maximum (RM) test (41, 54).
Furthermore, it is important to highlight that some variables considered to be crucial in the aging process were also evaluated. Cognitive status (Mini-Mental State Examination) was evaluated in 10 studies (36, 38–40, 42, 44–46, 50, 52) and quality of life in eight (34, 39, 42, 45, 46, 50, 52, 53). Eight studies assessed ADLs (34, 36, 39–41, 43, 45, 46) and six evaluated instrumental ADLs (38, 43–46, 52). Three studies used a visual analogue scale (39, 40, 43) and one article evaluated sitting time (47).

Results of physical exercise programs regarding physical fitness, functional capacity, and activities of daily living in oldest-old adults with physical frailty

The home-based exercise programs provided significant results in terms of physical fitness in eight studies (24, 35, 37, 38, 40, 42, 44, 54) and of functional capacity in seven studies (34, 36, 37, 42, 44, 50, 54). Among these results, the increase in muscle strength is particularly interesting (42, 44, 54), especially in the lower limbs (37, 54). Furthermore, there was improvement in habitual walking (37), the time in the stand up and sit-down test (34, 37, 42, 43, 54), flexibility (35), physical performance (37, 42), functional abilities (36, 37, 39, 42, 50), gait speed (42, 43, 50), balance (24, 50), and sedentary behavior (47). Improvements were also observed in the quality-of-life score (46, 50).
We highlight the importance of lower limb strength and its training in older adults with physical frailty. This physical fitness parameter is directly related to performance in tests of habitual walking, time to stand up and sit down, physical performance, functional abilities, gait speed, and balance (24, 34, 36, 37, 42–44, 50, 54).
Some of the results require careful interpretation. Three studies reported improvements and increases in scores or even indicated a trend towards positive results (24, 34, 42). However, some studies did not find a significant difference when the results were compared between the intervention and control groups or did not include a control group in the study (54). Furthermore, one study did not implement the intervention (52). We therefore emphasize the need for more in-depth studies on this topic.

 

Discussion

This scoping review aimed to map and describe home-based physical exercise programs for older adults with physical frailty. Considering the large number of definitions of frailty criteria that have been taking place, we chose to address various frailty criteria to make a large survey on home training in frail elderly people, and thus make a large mapping on the subject and its historical evolution, even before the concepts had been established in the literature. This scoping review aimed to map and describe home-based physical exercise programs for older adults with physical frailty. The results showed that the majority of studies adopted home interventions with a focus on progressive strength training, often incorporating external loads such as elastic bands or the individual’s own body weight. Within this context, improving muscle strength, especially in the lower limbs such as the quadriceps, has been shown to be intrinsically associated with optimizing functional mobility and promoting independence of older adults (54).
The results showed that the majority of studies adopted home interventions with a focus on progressive strength training, often incorporating external loads such as elastic bands or the individual’s own body weight. Within this context, improving muscle strength, especially in the lower limbs such as the quadriceps, has been shown to be intrinsically associated with optimizing functional mobility and promoting independence of older adults (54).
These observations are consistent with evidence showing correlations between a decrease in lean mass, deterioration of muscle quality, and decline in muscle function in the context of frailty (56). These factors collectively contribute to reducing physical function and quality of life, and even play a role as predictors of mortality (28). Furthermore, the findings of a meta-analysis revealed changes in muscle energy metabolism during exercise and its subsequent recovery, indicating that such interventions have the potential to positively affect muscle metabolism and, in turn, counterbalance the functional decline associated with frailty (57).
The study conducted by Browl and colleagues (35), which investigated the effect of flexibility training at home in older individuals with physical frailty, found improvements in the range of motion. Although the participants experienced gains in flexibility, no statistically significant results were obtained in terms of effectively preventing or reducing physical frailty. This finding underscores the importance of exploring home interventions that encompass physical fitness, including muscle strength, muscle power, aerobic endurance, balance, agility, flexibility, and joint mobility (19). Furthermore, the exercises should initially be implemented using a simple approach and subsequently progress to more complex activities (58), incorporating progressive intensity (39–41, 45, 51, 53, 54). These exercises often utilize body weight or resistance from an elastic band (24, 34–38, 40, 42, 45, 47, 50, 51). This approach aims to optimize the results of home physical exercise interventions for older adults with physical frailty, thereby consolidating its effectiveness as a treatment.
The study by McMurdo & Johnstone (34), a pioneer in this field, also examined the feasibility and effectiveness of home training for frail older people. They did not observe direct positive effects of the exercise but rather noted a trend, especially in the timed up-and-go test. The authors also highlighted the need for improvements in the methodology for future studies. Similarly, Helbostad and colleagues (39) recommended further research to investigate the effects of the duration, volume, and specificity of home training for older people with mobility restrictions. Furthermore, the authors emphasized the potential of home training to improve motor function and quality of life in frail older adults. Additionally, Gill et al. (36) proposed a deeper investigation of this topic.
It is also important to describe how the interventions were conducted in the studies. In some studies, oldest-old individuals exercised at home alone, either with or without the assistance of family members (34, 36–40, 45–47, 51). In most studies, the interventions were presented via illustrative leaflets (34, 36–38, 45–47, 51), often supplemented by instructional videos (42, 50–52). Notably, in these studies, trained professionals provided initial guidance during the first sessions.
Home-based training holds the potential to enhance the motor function and overall quality of life of frail older individuals. This particular intervention model was found to be well received by the participants in the studies, providing essential guidance for frail older individuals with limited mobility in their homes in order to prevent and delay the onset of physical frailty. However, long-term interventions considering the stratification of pre-frailty and physical frailty are still necessary. Guené-Huguet et al. (59) were the only researchers who implemented home-based exercises for elderly individuals with pre-frailty over a period of three years, employing a long-term approach. Notably, the authors observed positive results in terms of preventing physical frailty and considered the program to be cost effective.
One of the key findings of this review is that to help older adults adapt to exercise protocols, interventions should use progressive strength training tailored to their physical frailty (35-38, 41, 42, 45, 51, 53, 54). This means that when introducing a resistance program, the protocol should start with low intensity (50% 1RM) and gradually increase to high intensity (80% 1RM) during the specific training period (41, 45, 51, 53, 54). Another possibility for progress is the resistance of an elastic band, which can be modified by changing the color or thickness of the band. Physical assessments are important to structure a training protocol. The 1RM test is the method used to control intensity as a percentage of 1RM (41, 49). Furthermore, the Borg scale has also been used to monitor the intensity of training sessions at home and is easy to use by healthcare professionals (53).
The studies that investigated the adherence of participants to the home-based interventions (24, 34, 36–42, 44, 46, 47) reported high adherence rates, ranging from 72% to 89%. In addition, the single long-term study conducted by Guené-Huguet et al. (45), spanning three years of intervention, achieved an adherence rate of 67.6%. These findings robustly indicate that engaging in physical exercises at home is a well-accepted approach for elderly individuals with physical frailty, particularly those who encounter difficulties in participating in programs conducted outside the home, with the ultimate goal being the mitigation of physical frailty.
Home-based programs have shown better adherence of older adults than programs conducted outside the home (16). A recent review emphasized that physical exercise programs conducted in non-home settings are often associated with low adherence rates (26). In contrast, a meta-analysis found a low dropout rate from the program for older adults who engaged in physical exercise at home, with consequent improvements in ADLs (16). Thus, we underscore the importance of implementing home-based physical exercise programs dedicated to elderly individuals with physical frailty.

Gaps require studies on home-based physical exercise programs for oldest-old individuals with physical frailty

In the near future, we will witness a significant increase in the number of oldest-old individuals living at home. This fact highlights the crucial need to develop effective home-based exercise interventions that will preserve the independence of these individuals, delay institutionalization, and reduce hospitalizations. Within this context, we highlight the importance of studies that use specific approaches. In the modern post-pandemic scenario, for instance, the importance of home-based care through online devices has become apparent, along with the emergence of new applications for this purpose (19).
However, in the present review, only one study (52) was identified that used internet-based apps. It is worth noting that this study was conducted as a pilot trial and has not yet been clinically implemented. Furthermore, we found no systematic reviews with meta-analyses that met the inclusion criteria of this scoping review. These facts emphasize the need for primary research, including randomized clinical trials that employ validated measures to select and stratify oldest-old individuals with pre-frailty and physical frailty. Most of the studies included in this review highlighted the lack of comprehensive assessments in this context.
Furthermore, research is needed to explore the relationship between physical exercises and mental health in older individuals with physical frailty since they often face social isolation, a fact that renders this association more relevant at this stage of life. Additionally, a challenge for future research are long-term home-based physical training interventions. In this review, only one study (45) addressed this aspect. Moreover, clinical research is required to investigate exercises that simulate ADLs such as carrying groceries, climbing stairs, picking up objects from the floor, doing household chores, using the bathroom independently, dressing, and walking unaided. These exercises should include progressive load increments in order to increase daily body movements and provide challenges that will improve the mobility of this population.
During the database search for this review, we came across the Vivifrail project (https://vivifrail.com/), a program aimed at promoting physical exercises among frail older adults. This project is advancing towards providing home-based care for older adults in advanced age (19). However, we have so far not found applications that meet the inclusion criteria of this review, only studies involving institutionalized and hospitalized elderly individuals.
Finally, in addition to the mentioned approaches, future strategies should involve the integration and knowledge exchange among various healthcare professions such as physical therapists, physical education professionals, caregivers, occupational therapists, nurses, and doctors. These strategies should be based on appropriate methodologies for this population in order to establish a scenario of high-quality scientific production with methodological rigor in clinical studies. Such measures should permit not only to enhance scientific production but also to improve professional intervention and the quality of home care provided to this population.

Strengths and limitations

The scoping review has several strengths, including the participants selected, i.e., oldest-old individuals with physical frailty who received home-based care. This approach provided in-depth knowledge about a specific group of older adults and their characteristics since most studies focus on younger elderly individuals participating in physical exercise interventions outside of the home. Additionally, the search was conducted in major databases and no date restrictions were applied.
One limitation of the study is the fact that it included articles from the 1990s that exhibited lower methodological rigor in classifying older individuals with physical frailty. These studies did not employ tests considered the gold standard for identifying physical frailty, such as those proposed by Fried et al. (11). This fact may be attributed to the period when no clear conceptual definition of physical frailty existed and, consequently, no specific assessment measures were available.

 

Conclusion

The present review provided a comprehensive view of home-based physical exercise programs, demonstrating that these interventions are potentially safe and are associated with considerable adherence. The results highlighted the importance of muscle strength, especially in the lower limbs, as a key component for improving physical function in oldest-old individuals with physical frailty. Furthermore, the findings increase our understanding of a rapidly growing yet relatively unexplored population, highlighting the importance of prioritizing strategies that will prevent and delay physical frailty through home-based exercise programs.
The studies included in the review provide a modest but growing body of evidence on home-based exercise interventions for oldest-old individuals with physical frailty. However, significant uncertainties persist in these studies regarding the reversal of physical frailty, encompassing aspects such as quality of life and the need for long-term care of this population. Within this context, interdisciplinary research should be promoted, including experimental and longitudinal studies involving home-based exercise interventions. This will contribute to increasing scientific output in the field that will affect the work of healthcare providers.

 

Conflicts of Interest: The authors have no conflict of interests in relation to this scientific article.

Contribution declarations: All authors contributed to the conception and design of the study. The preparation of the material, data collection and analysis were carried out by Bruna Capanema, Felipe Fank, Maria C. Trento, Damiana Costa and Ana Rocha. The first draft of manuscript was written by Bruna Capanema. All authors commented on previous versions of the manuscript. All authors read and approved the final text manuscript.

Consent to Participate: Informed consent was obtained from all individual participants or their legal representatives included in the study.

Funding: This work was supported by National Council for Scientific and Technological Development (CNPq, Brazil), Coordination for the Improvement of Higher Education Personnel (CAPES, Brazil) and UNIEDU – program in the State of Santa Catarina run by the State Department of Education (SED).

 

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