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C. Udina1, J. Ars1, A. Morandi1, J. Vilaró2, C. Cáceres1, M. Inzitari1

1. REFiT Barcelona research group, Parc Sanitari Pere Virgili and Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain; 2. Blanquerna School of Health Sciences, Global Research on Wellbeing (GRoW), Universitat Ramon Llull. Barcelona, Spain.
Corresponding author: Cristina Udina, MD, Parc Sanitari Pere Virgili, C/ Esteve Terradas, 30, 08023 Barcelona, Spain, cudina@perevirgili.cat, ORCID ID: 0000-0002-0140-669X

J Frailty Aging 2021;in press
Published online January 18, 2021, http://dx.doi.org/10.14283/jfa.2021.1



COVID-19 patients may experience disability related to Intensive Care Unit (ICU) admission or due to immobilization. We assessed pre-post impact on physical performance of multi-component therapeutic exercise for post-COVID-19 rehabilitation in a post-acute care facility. A 30-minute daily multicomponent therapeutic exercise intervention combined resistance, endurance and balance training. Outcomes: Short Physical Performance Battery; Barthel Index, ability to walk unassisted and single leg stance. Clinical, functional and cognitive variables were collected. We included 33 patients (66.2±12.8 years). All outcomes improved significantly in the global sample (p<0.01). Post-ICU patients, who were younger than No ICU ones, experienced greater improvement in SPPB (4.4±2.1 vs 2.5±1.7, p<0.01) and gait speed (0.4±0.2 vs 0.2±0.1 m/sec, p<0.01). In conclusion, adults surviving COVID-19 improved their functional status, including those who required ICU stay. Our results emphasize the need to establish innovative rehabilitative strategies to reduce the negative functional outcomes of COVID-19.

Key words: COVID-19, older adults, therapeutic exercise, rehabilitation, post-ICU rehabilitation.



COVID-19’s impact increases with age (1). Besides mortality, patients may experience relevant disability, related to serious complications requiring Intensive Care Unit (ICU) admission, which has been linked to physical impairments (2). Less severe cases might experience functional decline due to immobilization due to the disease and isolation measures to prevent transmission. Early and effective rehabilitation interventions are urgent, despite healthcare systems may be overwhelmed and rehabilitation may be disrupted. Therapeutic exercise (TE) is a physical therapy technique used to improve or maintain a person’s physical condition through resistance, endurance, flexibility and balance training. The intensity, volume, progression and type of exercise must be individualized based on the physical condition and tolerance during the execution of TE. Previous research shows the benefits of supervised TE in acutely ill patients to improve their physical condition and autonomy through exercise (3). During the early weeks of the pandemic our post-acute care facility had to adapt in order to provide care for COVID-19 patients (4). In addition to maintaining the usual physical therapy interventions for more impaired patients, we created an intensive rehabilitation pathway through TE to facilitate a quick recovery and faster discharge at home. Our aim is to describe the pre-post impact on physical performance of multi-component therapeutic exercise for post-COVID-19 rehabilitation.



We performed a cohort study of post-acute care patients that overcame COVID-19 and were included in a rehabilitation protocol based on multi-component therapeutic exercise. The inclusion criteria were: 1) ability to walk unassisted pre-COVID-19 (use of cane or walker was allowed); 2) able to stand after the resolution of acute COVID-19; 3) social situation allowed discharge in 10 days. We collected demographics, COVID-19 related variables, comorbidities (sum of hypertension, diabetes, arrhythmia, myocardial infarction, Chronic Obstructive Pulmonary Disease/Asthma, mild cognitive impairment, dementia, other neurodegenerative diseases, stroke, depression, osteoarthritis and low back pain) and prevalence of polypharmacy (5 or more drugs) at admission. Our comprehensive assessment included: pre-COVID functional status with the Barthel Index and Lawton Index and frailty status with the Clinical Frailty Scale (CFS); cognitive function at post-acute admission with the Montreal Cognitive Assessment (MoCA) for global cognition and the Symbol Digit Modalities Test (SDMT) for attention and processing speed. SDMT scores are age-adjusted (5), considering a score of 7 or higher as normal range. The Confusion Assessment Method (CAM) was used to screen for Delirium. These covariates were collected based on clinical and functional aspects that might impact physical function as well as the response to physical exercise. We assessed physical function at day 1 and 10 of the intervention. Those patients who were discharged before day 10 were evaluated at discharge. We performed the Short Physical Performance Battery (SPPB) as a measure of gait performance (time to walk 4 meters), balance (stand for 10 seconds with feet side-by-side and in semi-tandem and tandem positions) and lower limb strength (time required to stand up and sit down 5 times from a chair without using the arms). Furthermore, we assessed independence for the basic activities of daily living with the Barthel Index, need of assistance to walk with the Functional Ambulation Category (FAC) (6) and the single leg stance test (7). We evaluated exercise capacity with the 6-minute walk test (6MWT) in a sub-sample (for logistical reasons).
The 30-minute 7 days/week multi-component therapeutic exercise intervention (summarized in Figure 1) was led by an expert physical therapist and combined: a) resistance training [1-2 sets with 8-10 repetitions each (intensity between 30-80% of the Repetition Maximum (8) )]; b) endurance training (up to 15-minutes aerobic training with a cycle ergometer, steps or walking) and c) balance training (walking with obstacles, changing directions or on unstable surfaces). Additionally, recommendations were provided to decrease daily sedentary behavior. Each session was individualized to each patient’s physical condition.
Outcome measures included: SPPB global score, gait speed (m/s), balance score and chair-stand time (seconds), Barthel Index score, ability to walk unassisted (FAC score 4 or higher) and maintain single leg stance for 10 seconds and distance walked during the 6MWT (meters). We used descriptive statistics with mean and Standard Deviation (SD) or frequencies as required. We assessed differences between the initial and final values in the outcome variables with Wilcoxon signed rank test and McNemar test for continuous and categorical variables, respectively. We calculated the mean pre-post change for each continuous outcome variable: Variable POST – VARIABLE PRE. We used Mann-Whitney U test to compare the mean change in the outcomes between patients treated or not in the ICU as well as to compare baseline characteristics in both groups. All statistical analysis was performed with statistical software: IBM SPSS Statistics for Windows, Version 21.0. (Armonk, NY: IBM Corp).



We included 33 patients (66.2±12.8 years, 57.6% women), of whom 90.9% (n=30) presented with pneumonia and 60.6% (n=20) were admitted to the ICU, all (n=20) requiring mechanical ventilation, with a mean ICU stay of 10.3±9.9 days. The sample consisted of pre-COVID-19 well-functioning adults (Barthel Index 98.5±5.8 and Lawton Index 6.7±2.1) with low frailty (CFS score 2.5±1.3) and comorbidity (sum of comorbidities 1.5±1.6) but high polypharmacy at admission (72.7% (n=24)). Post-ICU patients were younger, with lower comorbidity, better pre-COVID-19 functional status and lower frailty, compared to non-ICU patients (Table 1). Although none of the patients had delirium according to CAM scores at admission, post-COVID-19 cognitive function was mildly impaired in the whole cohort and within both groups. After the intervention (mean duration=8.2±1.7 days), all physical performance measures showed a statistically significant improvement when comparing the initial and final values in the global sample and among post-ICU patients, while non-ICU patients did not improve in balance-related variables. Furthermore, post-ICU patients experienced a greater improvement in SPPB and gait speed mean change compared to non-ICU (4.4±2.1 vs 2.5±1.7, p<0.01 and 0.4±0.2 vs 0.2±0.1, p<0.01, respectively). None of the patients died during the intervention and all were discharged home. In a subsample of 22 participants (61.9±12.1 years, 63.6% women, 81.8% admitted to the ICU and 95.5% with pneumonia), mean 6MWT walked distance improved from 158.7±154.1 to 346.3±111.5 m (p<0.001).

Table 1
Baseline characteristics and functional outcomes, in the total sample and stratified by previous ICU admission

Abbreviations: ICU: Intensive Care Unit. MoCA: Montreal Cognitive Assessment. CFS: Clinical Frailty Scale. SDMT: Symbol Digit Modalities Test. SPPB: Short Physical Performance Battery. FAC: Functional Ambulation Category. SDMT normal range ≥ 7. Legend: (*) Pre-post comparison within group with Wilcoxon rank test and McNemar test (significance at a p-level < 0.05 marked with †). (‡) Comparison of the mean change between the ICU and the non-ICU groups with Mann-Whitney U Test (significance at a p-level < 0.05 marked with †)

Figure 1
Scheme of the individualized multi-component therapeutic exercise intervention, combining 3 or more modalities daily

Abbreviation: RM: repetition maximum



In summary, in our sample of post-COVID-19 adults and older adults, physical function improved after a relatively short therapeutic exercise intervention. This improvement seems clinically meaningful, according to previous studies (9). Compared to the non-ICU group, post-ICU patients showed higher improvements, possibly due to their younger age and better functional, clinical and frailty status pre-COVID-19. Noteworthy, our sample showed mild cognitive impairment post-COVID-19 according to a brief cognitive assessment, which we might speculate as non-preexisting, especially in the ICU group, due to their relatively young age and preserved functional status. This cognitive dysfunction could be related to delirium during COVID-19’s acute phase or even be a neurological feature of COVID-19’s infection (10). Further research is needed to support these findings and to study long-term effects of COVID-19 on cognition.
Evidence about post-COVID-19 rehabilitation is still scarce, although there is a growing body of literature highlighting the need of rehabilitation strategies. To our knowledge, this is the first study on the effects of intensive rehabilitation through a structured therapeutic exercise intervention of post-COVID-19 patients in post-acute care, a setting able to combine the acute management of these patients with rehabilitative interventions (4). Improving physical function in post-ICU patients is crucial as previous research has shown long-term negative outcomes (11). However, the type of exercise intervention previously reported in post-ICU rehabilitation so far seems not comparable to our intensive and multimodal protocol (12). Previous research shows the efficacy of similar therapeutic exercise strategies tested in acute geriatric units, demonstrating functional benefits of short-term supervised exercise during acute medical illnesses: the reported magnitude of change of 2.4 points in the total SPPB (13) is similar to the change in our non-ICU group, which is indeed older and with a slightly pre-COVID-19 worse clinical and functional profile, compared to the ICU group. According to studies performed with Acute Respiratory Distress Syndrome survivors, the improvement in exercise capacity experienced in the small subsample seems also clinically relevant (14). The cognitive impairment detected among the post-ICU patients is also in line with the findings reported in Acute Respiratory Distress Syndrome survivors (15), however in our opinion the impairment detected in non-ICU patients, deserves further research to shed some light into the potential neurological manifestations of COVID-19.
Main limitations of the study are the small sample size and the absence of a control group to assess the effect of the intervention. Among the strengths, we enrolled adults and older adults post-COVID-19 with different acute care pathways during the acute phase, with a comprehensive assessment of clinical and functional variables.
In conclusion, adults and older adults surviving COVID-19 seem to improve their functional status, despite previous admission to ICU, through a short, individualized, multi-component therapeutic exercise intervention. Further research with controlled, larger samples and longer treatment periods might help elucidate the role of rehabilitation interventions in the reduction of negative functional outcomes of COVID-19, hence mitigating the potential increase in COVID-19-related disability and health care costs.


Funding: This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interests: The authors (CU, JA, AM, JV, CC) state that they have no financial nor non-financial conflict of interests. MI received from Nestlé a fee for scientific advice, not related to the work or the topic of the current manuscript.
Ethics approval: The study procedures were approved by the institutional ethics committee. The authors declare that all study’s procedures are according to the 1964 Helsinki Declaration and that personal participant’s information was treated to ensure complete privacy. Furthermore, all procedures performed during the study were in the context of usual care of patients admitted to post-acute care.



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A. Takaoka1, D. Heels-Ansdell1, D.J. Cook1,2, M.E. Kho3


1. Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Canada; 2. Department of Medicine, Faculty of Health Sciences, McMaster University, Canada; 3. School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Physiotherapy Department, St. Joseph’s Healthcare Hamilton, Canada.
Corresponding author: Michelle E. Kho, PhD, PT, School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Physiotherapy Department, St. Joseph’s Healthcare Hamilton, Institute of Applied Health Sciences, 1400 Main St. W. Hamilton, ON L8S 1C7, Email: khome@mcmaster.ca, Telephone: (905) 525-9140 x28221,
Fax Number: (905) 524-0069

J Frailty Aging 2021;10(1)49-55
Published online October 5, 2020, http://dx.doi.org/10.14283/jfa.2020.52



Background: Physical therapy initiated early in an ICU stay may reduce functional deficits in critically ill patients; however, the association of frailty with outcomes in those receiving early in-ICU rehabilitation is unknown. Objective: To estimate the association between frailty and 3 outcomes in patients enrolled in an ICU randomized clinical trial (RCT). Design: Exploratory secondary analyses of the CYCLE pilot RCT (NCT02377830). Setting: 7 Canadian ICUs. Participants: Previously ambulatory critically ill adults. Intervention: Participants were randomized to early in-bed cycling plus routine physiotherapy versus early routine physiotherapy alone. Measurements: Using regression analyses, we modelled the association between pre-hospital Clinical Frailty Scale (CFS) scores, Physical Function in ICU Test-scored (PFIT-s), muscle strength, and mortality at hospital discharge, adjusting for illness severity (APACHE II) and the randomized intervention. We explored the influence of imputing mean PFIT-s and strength scores for decedents, and with listwise deletion of decedents in a sensitivity analysis. Results: Of 66 patients, 2 had missing data, 2 had incomplete data, and 21 died by hospital discharge. At hospital discharge for 66 patients, frailty was not associated with PFIT-s (mean difference (MD) [95% CI]=0.20, [-2.08, 2.74]) or muscle strength (1.96, [-12.6, 16.6]). A sensitivity analysis yielded consistent results. Frailty was also not associated with hospital mortality (odds ratio 0.91, [0.28 to 2.93]). Conclusion: We found no association between pre-hospital frailty, physical function, strength, or mortality at hospital discharge in critically ill patients enrolled in an early rehabilitation trial. Larger sample sizes are needed to further explore the association of frailty with these outcomes at hospital discharge.

Key words: ICU, rehabilitation, frailty, outcomes, mechanical ventilation.




Frailty is a patient health state characterized by losses in one or more domains of function (1, 2). In critically ill patients, a systematic review identified a 30% (95% CI: 29 to 32) baseline prevalence of frailty across 10 studies and 3030 participants (3). Regardless of frailty instrument used, patients with baseline frailty are consistently at a greater risk of functional dependence, disability, and mortality following critical illness (4–6). As the number of mechanically ventilated patients are projected to increase due to an aging baby boomer population (7), the impact of frailty is an urgent health concern across the continuum of care.
Rehabilitation initiated early in an ICU stay is a promising intervention to improve outcomes in critically ill adults (8). Increasing evidence has demonstrated that preserved physical fitness may be associated with lower 1-year mortality in elderly patients with frailty (9); however, to our knowledge, no studies have examined the association of frailty on the outcomes of patients receiving early rehabilitation in the ICU.
We recently completed a 7-centre pilot study of early leg cycle ergometry with mechanically ventilated patients who were ambulatory and independent prior to critical illness (10, 11). Using the study database, we conducted an exploratory analysis to evaluate the association between pre-hospital frailty status and hospital discharge measures of physical function, muscle strength, and mortality. We hypothesized that patients with frailty would have worse physical function, less muscle strength, and higher mortality at hospital discharge.




This study was approved by the Hamilton Integrated Research Ethics Board (#14-531).

Design, Patients and Settings

We conducted a preliminary, exploratory multivariable regression analyses of the CYCLE (Critical Care Cycling to Improve Lower Extremity Strength) pilot randomized controlled trial (RCT) (NCT02377830) that enrolled 66 critically ill patients across 7 Canadian ICUs. The methods and results of the RCT are described elsewhere (10, 11). Briefly, patients were included if they were >18 years old, admitted within the first 4 days of mechanical ventilation and first 7 days of ICU, and independently ambulated with or without a gait aid before their critical illness. Primary exclusion criteria were any conditions impairing cycling, proven or suspected neuromuscular weakness, inability to follow commands in English, a temporary pacemaker, expected risk of hospital mortality >90%, palliative goals of care, or persistent exemptions precluding cycling. Enrolled patients were randomized to receive early in-bed cycle ergometry (30 minutes, 5 days/week, up to 28 days or ICU discharge) plus routine physiotherapy or early routine physiotherapy alone for the duration of their ICU stay.

Dependent Variables

At hospital discharge, trained physiotherapists blinded to treatment allocation measured function using the Physical Function in ICU Test-scored (PFIT-s) (12) and strength using the Medical Research Council Sum Score (MRC-SS) (13). Research coordinators documented hospital vital status (dead/alive).

Independent Variable

Research coordinators evaluated frailty status in the 1-2 weeks before current hospital admission using the Clinical Frailty Scale (CFS) (2). These scores were generated at trial enrollment through family member and/or patient interviews and comprehensive chart reviews.


We included covariates in our models to adjust for potential confounders. To address sample size limitations and to avoid overfitting models, we strategically limited the number of predictors in our models (>10 participants per predictor in linear models; >10 events per predictor in logistic models (14)). We purposefully selected 2 covariates a priori based on possible confounders of the relationships between pre-hospital frailty and our 3 outcomes. Our first covariate was illness severity (15–17) measured using the APACHE II (Acute Physiology and Chronic Health Evaluation II) score (18). We considered age as a covariate because of its association with both frailty and our outcomes of interest; however, since age contributes to overall APACHE II scores, we did not include it as a separate variable to avoid redundancy. Our second covariate was the randomized intervention, cycling plus routine physiotherapy versus routine physiotherapy alone, given the context of this analysis nested within the CYCLE pilot RCT.
Detailed descriptions of variables and covariates are provided in Table e1 (e-supplemental appendix).


We tabulated descriptive statistics of baseline variables (e.g., age, sex, BMI, admission type, APACHE II scores (18), Charlson Comorbidity Index (19), Functional Comorbidity Index (20), pre-ICU Functional Status Score for the ICU (FSS-ICU) (21), pre-ICU Katz Independence in Activities of Daily Living (Katz ADL) scores (22)) and trial-related characteristics (e.g., group allocation, time to first session, total days of rehabilitation, length of stay in ICU and hospital, outcomes) according to dichotomized frailty status, with frailty defined as a CFS score >5. For continuous variables, we reported means and standard deviations (SD), or medians and interquartile ranges (IQR) if data were not normally distributed. We compared characteristics of patients with and without frailty using Student’s t-tests or Mann-Whitney U tests as appropriate. We reported categorical variables as counts and proportions, and compared groups using Pearson’s chi-square test.
We performed confirmatory multivariable linear regression to estimate the association between pre-hospital CFS scores, PFIT-s, and MRC-SS. We used binary logistic regression to model the association between pre-hospital CFS scores and hospital survival. In both models, we dichotomized patients by CFS scores for enhanced clinical interpretability. Linear regression results are presented as mean difference (MD) and 95% confidence intervals (CI). Overall model statistics are reported as R2 and F values with degrees of freedom (df numerator, df denominator) in the e-supplemental appendix. Logistic regression odds ratios (OR) are presented with 95% confidence intervals. We considered a p-value <0.05 statistically significant for all tests. All analyses were performed using SPSS (IBM Corp. Released 2016. IBM SPSS Statistics for Macintosh, Version 25.0. Armonk, NY: IBM Corp.).

Missing Data

For patients with missing PFIT-s or MRC-SS data, when possible, we used ICU discharge scores under the rationale that ICU scores were based on the patient’s own data and would provide a conservative estimate of outcome data at hospital discharge. For patients who died, we assigned PFIT-s and MRC-SS of 0 under the assumption that those who died would have little to no function or muscle strength. We conducted sensitivity analyses to explore the influence of these imputations for decedents (23).

Sensitivity analyses

Based on methodology adapted from Murphy et al. (23), we assessed our continuous outcome models with 1) listwise deletion, wherein only complete cases were included, and 2) imputed data using mean scores.



We enrolled 66 patients in this pilot RCT (cycle intervention: n=36, control: n=30) with a mean (SD) age of 61.6 (16.9) years and APACHE II score of 23.5 (8.6) (Table 1). The prevalence of frailty (CFS>5) in our cohort was 26% (17/66) (Figure 1). Baseline characteristics were similar between those with and without frailty, with the exception of more surgical admissions (p=0.019) and unexpectedly higher Katz ADL scores (p<0.001), and higher FSS-ICU (p<0.001) in those with frailty (Table 1). Twenty-two (33%) patients died in hospital (36% with frailty, 33% without frailty) (Table 2). There were no differences in trial-related physiotherapy characteristics, including time to first physiotherapy session or total days of rehabilitation, between those with frailty and those without (Table 2).

Figure 1
Clinical Frailty Scale (CFS) scores

Distribution of Clinical Frailty Scale (CFS) scores. Overall prevalence of frailty (CFS>5) was 26% (17/66).

Table 1
Baseline characteristics of patients enrolled in the CYCLE pilot RCT, by frailty status

α. Pearson Chi Squared Test; β. Mann-Whitney U Test; γ. n=48 (one missing value); δ. equal variances not assumed; BMI- Body Mass Index; APACHE II- Acute Physiology and Chronic Health Index II Score; FSS-ICU- Functional status score for ICU; Katz ADL- Katz Activities of Daily living


Table 2
Trial and outcome characteristics of patients enrolled in the CYCLE pilot RCT, by frailty status

α. Excludes ICU discharge scores for 2 patients with missing hospital discharge assessments due to unexpected discharge; β. Excludes ICU discharge scores for 2 patients with incomplete hospital discharge assessments; Pearson’s Chi Squared Test for categorical variables; Mann-Whitney U Test for continuous variables


One patient completed PFIT-s and MRC-SS assessments while waiting to be discharged from hospital, but subsequently deteriorated, was re-admitted to ICU and died during the index hospitalization. The remaining 21 decedents were assigned PFIT-s and MRC-SS of 0. Four patients survived, but had some missing data. For the 2 (3%) patients with missing PFIT-s and MRC-SS due to unexpected hospital discharge, and 2 (3%) patients with partially completed MRC-SS (Figure 2), we used the corresponding ICU discharge measures in place of hospital discharge scores.

Figure 2
Flow diagram of patients enrolled in CYCLE Pilot RCT by frailty status


Patient flow diagram by frailty status. PFIT-s – Physical Function in ICU Test-scored; d/c – discharge; ax – assessment; MRC-SS – Medical Research Council Sum Score. N=23 patients missed PFIT-s assessments in hospital due to death. N=2 patients had missed PFIT-s and MRC-SS assessments due to unexpected discharge from hospital. N=2 patients had only partial MRC-SS scores completed.


At hospital discharge, frailty was not associated with PFIT-s scores (MD= 0.20, 95%CI: -2.08 to 2.74) or muscle strength (MD=1.96, 95% CI: -12.6 to 16.6). These results were consistent in the sensitivity analyses. Frailty was not associated with in-hospital mortality (OR= 0.91, 95% CI: 0.28 to 2.93). We report full details of each model in eTable 2 and eTable 3, and results of the sensitivity analyses in eTable 4, and eFigures 1 and 2 in the e-supplemental appendix.



In this cohort of previously ambulatory critically ill patients enrolled in a trial of early rehabilitation, our exploratory analyses demonstrated that pre-hospital frailty status measured using the CFS was not associated with physical function, muscle strength, nor mortality at hospital discharge, after adjusting for severity of illness and randomized assignment.
Our baseline frailty prevalence was 26% (95% CI: 15.4 to 36.6), which was similar to the 30% (95% CI: 29 to 32) prevalence reported in previous prospective ICU studies summarized in a systematic review (3). Although the wide confidence interval surrounding our estimate indicates a high degree of imprecision, our slightly lower observed prevalence may reflect our inclusion criteria which required patients to ambulate independently before their critical illness (10, 11). The high level of baseline independence in this cohort may also explain the unexpectedly higher Katz ADL and FSS-ICU scores in those who were frail; however, these differences may also be due to chance, given our small sample size. Our results may also differ from this systematic review because the pooled estimate in the review included several distinct measures of frailty, including the CFS, Frailty Index (24), and Frailty Phenotype (1). Both the Frailty Index and Frailty Phenotype tend to report a higher frailty prevalence compared to the CFS (25, 26).
We found no association between frailty measured using the CFS and hospital mortality in our small cohort of patients. Our results are similar to 3 studies in critically ill patients that did not find an association between frailty and mortality at hospital discharge (5, 27, 28). In contrast, 3 prospective studies demonstrated associations between higher CFS scores and hospital mortality (4, 25, 26). Bagshaw et al. conducted a 6-center prospective cohort study enrolling 421 medical-surgical patients with a frailty prevalence of 32.8% and demonstrated higher in-hospital mortality among patients with frailty (adjusted OR 1.81, 95% CI: 1.09 to 3.01) (4). Of the remaining two studies, patients with frailty were also more likely to die in hospital (25, 26). Compared to our cohort, differences in previous study results could be due to patient population (high proportion of trauma patients), or use of unadjusted analyses (univariate logistic regression and Chi square) (25, 26).
Our results also differ from previous studies examining the relationship between frailty and function in ICU survivors. Three studies reported different results over time for the association between frailty and function (4, 5, 28). Hope et al. reported an association between pre-ICU frailty disability in activities of daily living (ADLs) at 6-months after hospital discharge, but not at the time of hospital discharge (28). Brummel et al. demonstrated an association between higher CFS scores and greater odds of disability in instrumental activities of daily living (iADL), but not ADLs at 3- and 12- months post-hospital discharge (5). Bagshaw et al. demonstrated an independent association between pre-ICU frailty (CFS ≥5) and the odds of self-reported new functional dependence at 6- and 12-months after hospital discharge (OR 2.25, 95% CI 1.03 to 4.89) (4). Our results may differ from previous research because of different measurement methods (patient self-report vs. performance-based measures), timing of measurements, or the possibility of type-II error due to small sample size.
The previously cited studies did not document receipt of rehabilitation during the ICU stay. Our physical function results are similar to a single-centre retrospective study of 264 patients who received early progressive mobilization in a cardiovascular ICU (CVICU) (29). Patients ≥60 years old, admitted to a 12-bed CVICU and meeting eligibility criteria, received early mobilization activities. Mobilization activities varied from bed/cardiac chair (Level 1) to independent/modified independent walking >50 feet (Level 4). The prevalence of frailty measured by the CFS was 34.1% (90/264). In a multivariable model, after adjusting for age, sex, and severity of illness (APACHE III score), there was no difference in change in level of function at CVICU discharge between patients with or without frailty. Similar to other studies, patients with frailty had higher hospital mortality (8.9%) than those without (5.7%), however the authors did not conduct an adjusted analysis (29).
Differences in patient population, analysis methods, outcome measurement, exposure to ICU rehabilitation interventions, and study design may account for discordant results between the current study and previous research. Prospective and historical cohort studies may be limited by confounding as well as availability and quality of data. Previous studies had broad inclusion criteria, whereas our study focused on patients who could ambulate before their critical illness. Few studies documented receipt of ICU rehabilitation interventions. Our study included a sample of medical-surgical critically ill patients from 7 institutions, both the intervention group and control group started rehabilitation within a median (IQR) of 3 (2-4) days from ICU admission, and patients completed performance-based measures (10, 11). Rehabilitation in ICU is a promising intervention to improve muscle strength, functional capacity, and walking distance at ICU discharge. It may also shorten length of stay in both ICU and hospital, and improve health related quality of life at hospital discharge (30) and 6-months post discharge (31–33). We hypothesize that rehabilitation interventions could have a moderating effect on the functional deficits experienced by ICU survivors with frailty meeting strict inclusion criteria in clinical trials.
Our study had limitations. Our small sample size restricted the number of covariates that could be included in models and rendered our results underpowered and at risk of residual confounding. With a larger sample, we would have controlled for other known confounders including the functional comorbidity index, Katz-ADL, or body mass index. We dichotomized CFS scores for clinical interpretability. Furthermore, missing dependent variables due to death were imputed based on clinical rationale which may have created biased estimates (34); however, our sensitivity analyses explored the robustness of our imputation decisions.
Strengths of this study included the use of known confounders in regression models regardless of their statistical significance in the model (35). Trained physiotherapists, blinded to treatment allocation and frailty assessment conducted our performance-based function and strength measures. We had limited missing outcome data due to loss to follow up and managed these missing values using conservative estimates. Finally, this was the first prospective study of the association between frailty and outcomes of physical function, muscle strength, and mortality in a cohort of critically ill patients enrolled in an early ICU rehabilitation trial.
There is a projected future increase in our aging population and subsequently the number of mechanically ventilated patients (7). These findings support a larger research effort towards developing and studying interventions which aim to decrease healthcare system burden and resource utilization associated with the growing population of individuals living with frailty (36). To facilitate evaluation of the association of frailty with function, we suggest that future studies include common measures at similar time points. Recent papers on core outcome sets for studies of patients with acute respiratory failure (37), mechanical ventilation (38), and critical care rehabilitation studies (39) and frailty (in progress) support this premise.



We found no association between pre-hospital frailty and physical function, muscle strength, or mortality at hospital discharge in previously ambulatory critically ill patients enrolled in an early rehabilitation trial. Larger sample sizes are needed to further explore the influence of frailty on short-term outcomes after hospitalization.


Declaration of Author(s) Competing Interests: None.
Clinical Trials Registration Number: NCT02377830
Funding Statement: This work was supported by grants from Technology Evaluation in
the Elderly Network Catalyst (now Canadian Frailty Network; CAT2014-05), Canadian Respiratory Research Network Emerging Research Leaders Initiative, Ontario Thoracic Society Grant-in-Aid and Canadian Institutes of Health Research Transitional Operating Grant (Award #142327), Canada Foundation for Innovation, and the Ontario Ministry of Research and Innovation. MEK and DJC are each funded by a Canada Research Chair. AT was supported by Canadian Frailty Network Interdisciplinary Fellowship Award (IFP-2018). Restorative Therapies (Baltimore, MD) provided 2 RT-300 supine cycle ergometers for Toronto General Hospital and London Health Sciences sites for this research.
Acknowledgments: We would like to acknowledge the CYCLE Pilot RCT participating centers: St. Joseph’s Healthcare Hamilton, Juravinski Hospital, Hamilton General Hospital, Toronto General Hospital, London Health Sciences – Victoria, St. Michael’s Hospital, and Ottawa General Hospital. http://icucycle.com/cycle-rct/
Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.




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1. Department of Rehabilitation I, School of Medicine, Fujita Health University, Aichi, Japan; 2. Department of Rehabilitation Medicine, National Center for Geriatrics and Gerontology (NCGG), Aichi, Japan
Corresponding author: Izumi Kondo, Department of Rehabilitation Medicine, National Hospital for Geriatric Medicine, National Center for Geriatrics and Gerontology (NCGG), 7-430 Morioka-cho, Obu City, Aichi Prefecture, Japan, Fax: +81-562-44-8518, Phone: +81-562-46-2311, E-mail: ik7710@ncgg.go.jp

J Frailty Aging 2018;7(1):47-50
Published online October 4, 2017, http://dx.doi.org/10.14283/jfa.2017.40



The reported prevalence of sarcopenia has shown a wide range, crucially based on the diagnostic criteria and setting. This cross-sectional study evaluated the prevalence of sarcopenia and sought to identify factors associated with sarcopenia on admission in a specialized geriatric rehabilitation setting based on the newly developed the Asian Working Group for Sarcopenia algorithm. Among 87 participants (mean age, 76.05 ± 7.57 years), 35 (40.2%) were classified as showing sarcopenia on admission. Prevalence was high, particularly among participants ≥80 years old, with tendencies toward lower body mass index, smoking habit, lower cognitive function, and greater functional impairment compared with the non-sarcopenic group. Identification of sarcopenia in elderly patients before rehabilitation and consideration of risk factors may prove helpful in achieving rehabilitation outcomes.

Key words: Elderly, hospitalization, prevalence, rehabilitation, sarcopenia.




Sarcopenia is understood as a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass, muscle strength and integrity (1). The adverse consequences of sarcopenia include an increased risk of falling, decreased ability in activities of daily living, mobility disorders, and higher morbidity and mortality among the elderly (2). The significant clinical impact of sarcopenia on the elderly increases the burden on the healthcare system (3).
The prevalence of sarcopenia as defined according to the European Working Group on Sarcopenia (EWGSOP) criteria is high among older inpatients, at 21.4-25.3% in acute geriatric units 4, 5) and around 46% in post-acute geriatric units (6). Although the sarcopenic prevalence among geriatric hospitalized patients has been relatively well examined, research data on sarcopenia in geriatric settings dedicated to rehabilitation remains scant. In addition, the sarcopenic prevalence as reported from epidemiological and interventional studies have differed markedly, making comparisons and interpretation difficult (7).
In 2014, The Asian Working Group for Sarcopenia (AWGS) proposed the AWGS diagnostic criteria of sarcopenia for Asian populations. The few studies that have examined sarcopenia mainly in community-dwelling elderly individuals based on AWGS criteria have shown a prevalence of around 7-10% (8, 9). The aim of this study was to determine the prevalence of sarcopenia based on the AWGS algorithm and to identify factors associated with sarcopenia among elderly patients admitted for specific rehabilitation treatment.



This study was conducted in elderly patients admitted to the acute geriatric ward dedicated for rehabilitation. Participants comprised individuals ≥60 years old with a stable medical condition, and sufficient cognitive function to perform tests (37 males, 50 females; underlying pathology: 39.1% fracture, 21.8% stroke, 20.7% postsurgical osteoarthritis, 18.4% others). Patients with severe medical or psychiatric illness, bedridden status, peripheral vascular disease with intermittent claudication, acute arthritis, severe pulmonary disease, heart failure, or specific muscular disease were excluded. All participants provided written informed consent. The institutional review board approved this study.


Baseline characteristics were collected. All tests and assessments for the diagnosis of sarcopenia and nutritional screening as well as functional assessments, including the Functional Independence Measure (FIM), Mini Mental State Examination (MMSE) were conducted within 2 days of admission or once a stable condition was achieved. Nutritional status was assessed using prealbumin and transferrin, which have been proposed as earlier nutritional markers due to shorter half-lives than albumin, and offer sensitive parameters for the efficacy of nutritional support as well as the preferred marker for malnutrition (10). All participants were managed with proper dietary nutrition by the rehabilitation team and nutritionists.

Diagnostic criteria for sarcopenia

The AWGS criteria were used to diagnose sarcopenia according to low muscle mass, low muscle strength, and/or low physical performance (11). Measurement of muscle strength and physical performance were utilized for screening. In cases where patients could not perform either activity, the score was taken as zero and assessment continued to the next step. Muscle mass was measured using bioelectrical impedance analysis (BIA), obtained using a Multi-Frequency Body Composition Analyzer (MC-180; Tanita, Japan). Suggested cut-off values were <7.0 kg/m2 for men and <5.7 kg/m2 for women, defined by appendicular skeletal muscle mass/height2. Muscle strength was assessed using a handgrip dynamometer. Three measurements with 1-min rest intervals were taken using the dominant hand unless this was unusable, and the mean was calculated. Strength cut-offs of <26 kg and <18 kg were classified as indicating low muscle strength for men and women, respectively. Physical performance was identified by 6-m usual gait speed. Timing was started on initiation of foot movement and stopped when one foot contacted the ground crossing the 6-m end line. The fastest of two trials was used for analysis. A cut-off of ≤0.8 m/s was used to identify low performance. All data were analyzed using SPSS 19.0 (SPSS Inc., Chicago, IL). Chi-square test was applied to compare the associated risk factors between patients with and without sarcopenia, and the diagnostic criteria of sarcopenia among three age groups. P-values <0.05 were considered statistically significant.



The mean age of participants was 76.05 ± 7.5 years (range, 18.4% at 60-69 years, 49.4% at 70-79 years, 32.2% at ≥80 years). The prevalence of sarcopenia using AWGS criteria was 40.2% (Figure 1).

Figure 1 Diagnosis of sarcopenia according to the AWGS algorithm

Figure 1
Diagnosis of sarcopenia according to the AWGS algorithm


Participants were stratified into three age groups to compare the effects of age on sarcopenia (Table 1). Significant differences in sarcopenic prevalences, low muscle mass and low muscle strength (p = 0.024, 0.018, 0.047, respectively) were seen among age groups. Compared to non-sarcopenic patients, sarcopenic patients were significantly older from the age of 70 (40% at 70-79 years, and 48.6% at ≥80 years; p = 0.024).

Table 1 Prevalence of sarcopenia and diagnostic criteria in each age group

Table 1
Prevalence of sarcopenia and diagnostic criteria in each age group

P-values were obtained using the chi-square test.


Furthermore, mean BMI was lower in sarcopenic patients (19.55 ± 3.1 kg/m2) than in non-sarcopenic patients (24.49 ± 3.2 kg/m2; p < 0.001). In the sarcopenic group, 34.3% were underweight (<18.5 kg/m2), compared to 0% in the non-sarcopenic group (p < 0.001). In contrast, overweight (25-29 kg/m2; 30.8%) and obese (≥ 30 kg/m2; 3.8%) patients were only seen in the non-sarcopenic group. Patients with sarcopenia showed lower cognitive function as measured by the MMSE and cognitive FIM (p = 0.002 and < 0.001 respectively), and lower functional ability as measured by total FIM (p = 0.012). Smoking was more frequent among sarcopenic patients (p = 0.035). No significant differences in prealbumin or transferrin levels were seen.



This report identified a high prevalence of sarcopenia according to AWGS criteria in elderly patients admitted for rehabilitation, particularly among those >80 years old, and demonstrated significant differences in age-dependent prevalence.
The AWGS proposed a similar approach for sarcopenia diagnosis, but, unlike the EWGSOP, recommended measuring both muscle strength and physical performance as screening tests with different cutoff criteria based on current evidence from Asian populations, which may differ from Caucasian populations in terms of body size, lifestyle, and cultural background (11). After establishing the AWGS algorithm in 2014 (11), emerging evidence based on the AWGS was published. In a recent cohort of community-dwelling elderly individuals (12), the sarcopenic prevalence according to the AWGS was 9.6% in men and 7.7% in women, supporting studies by Yu et al.8 and Lee et al. (9) (9.4% and 7.6% overall, respectively). Compared to this report, the lower rate of sarcopenia could be due to enrollment of community-living participants with no acute illness, representing a healthier group than hospitalized elderly individuals.
Regarding sarcopenia among elderly inpatients, previous studies have reported prevalences over a wide range (6.6-46%), and those studies were conducted using EWGSOP criteria (4-6). In this present result, the prevalence of sarcopenia based on AWGS criteria was high (40.2%). Further study would be useful for determining the consistency of sarcopenic prevalence according to AWGS criteria.
Sarcopenia appears to increase with advancing age, particularly in patients ≥80 years old (Table 1). This confirmed that age acts as a determinant of risk factors associated with sarcopenia. While focusing on age groups individually, one-third of patients aged 70-79 years and one-quarter of those aged 60-69 years were identified with sarcopenia. Furthermore, up to 60.7% of patients ≥80 years old had sarcopenia. Compared to prior studies using the AWGS algorithm, the prevalence of sarcopenia in similar age ranges was higher in this report. One study8 reported that community-dwelling elderly individuals ≥65 years old showed a 9.4% prevalence of sarcopenia. Another study9 divided participants into 2 groups (≥75 and <75 years), revealing a higher rate of sarcopenia in the older group (17.6% vs. 5.6%). Although sarcopenic prevalences in previous studies appeared to intensify with aging, as in this report, the percentages were obviously lower. This could be due to hospitalized elderly individuals having complicated health problems and therefore a higher risk of sarcopenia, suggesting the importance of early recognition and consideration of specialized healthcare, especially for hospitalized elderly patients.
The significantly lower BMI in sarcopenic patients was seen alongside a high percentage showing underweight status (34.3%), compared to none in the non-sarcopenic group. Conversely, overweight status was found only in the non-sarcopenic group. This suggests that increasing weight might contribute to a lower risk of sarcopenia, and declines in BMI could represent a manifestation of insufficient nutritional intake, leading to muscle loss, and increasing risk of sarcopenia. Prealbumin and transferrin concentrations tended to be lower in sarcopenic patients, although no significant differences were identified. Prealbumin and transferrin might not be sensitive enough to capture actual changes in nutritional condition. Further research using other nutritional parameters should be examined to confirm the correlation between sarcopenia and malnutrition.
Sarcopenia was associated with smoking, consistent with previous findings (13, 14). Comparisons also identified lower cognitive function and functional status in sarcopenic elderly individuals. While sarcopenia is understood to play a major role in contributing to physical decline, the relationships with cognitive declines remain unclear (15).
The limitations of this study were the relatively small sample sizes recruited from a single institute. Thus, the results may not be representative of geriatric rehabilitation inpatients. Nevertheless, the present findings depicted a high rate of sarcopenia among hospitalized elderly individuals and contributed insights into age-related sarcopenia. Initial screening for sarcopenia may be warranted before starting rehabilitation treatment.


Funding: This study was supported by research grants from the National Center for Geriatrics and Gerontology (NCGG), Japan.
Acknowledgments: We wish to thank all the study participants and health professionals involved in obtaining clinical measurements.
Disclosure statement: The authors declare no conflicts of interest.



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1. Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA; 2. College of Nursing, University of Colorado, Aurora, CO, USA; 3. Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA
Corresponding author: Jennifer E. Stevens-Lapsley, University of Colorado, 13121 East 17th Avenue, Aurora, CO 80045, Office: (303) 724-9170, Fax: (303) 724-9016, Jennifer.stevens-lapsley@ucdenver.edu


J Frailty Aging 2017;6(1):2-5
Published online October 5, 2016, http://dx.doi.org/10.14283/jfa.2016.110



 Frailty is an emerging and immediate public health concern given the growing aging population. The condition of frailty is characterized by a reduction in physiologic reserve, which places frail older adults at considerable risk for further functional decline, hospitalization, institutionalization, and death. Recent research suggests that frailty may be reversible, which could result in significant improvement in public health. Thus, a strong impetus exists to develop strategies for frail older adults that achieve the Triple Aim through better promotion of population health, optimization of patient experiences, and delivery of high-quality care at minimal cost. Physical therapists often treat frail older adults, yet how physical therapists can contribute to preventing or reversing frailty in healthcare settings has not been described, and may potentially influence patient outcomes and healthcare spending. Therefore, the purpose of this publication is to outline the potential role of physical therapists in achieving the Triple Aim for the frail older adult population.

Key words: Rehabilitation, frail older adults, frail elderly, physical therapy specialty, triple aim.



The prevalence of frailty is anticipated to dramatically increase in the United States as the percent of older adults rises (1, 2), with current estimates of frailty across community-dwelling older adults varying between 4-59% (3). Frail older adults are characterized as having a loss of physiologic reserve that results in an inability to maintain homeostasis in the presence of external stressors (e.g., surgery, falls, or illness)(2, 4, 5). Reduced physiological reserve may manifest in higher rates of hospitalization, institutionalization, disability, and mortality (4). As a result, older adults with greater indices of frailty accrue 22-46% higher healthcare costs following hospitalization compared to those with minimal frailty (6). In addition, frailty has a negative impact on both physical and mental quality of life (QOL)(7). Thus, the need to identify frailty early and intervene in a timely manner is an emerging public health concern because of the impending, exponential growth of the aging population and the subsequent increase in healthcare burden (8). Healthcare providers are being challenged to achieve the Triple Aim of improving population health, reducing per capita costs, and optimizing patient experience for frail older adults (9).
In 2012, the International Association of Gerontology & Geriatrics and The World Health Organization developed a consensus statement that promotes frailty screening as a strategy for identifying vulnerable, frail older adults and initiating interventions to allow “aging in place” (10, 11). However during patient visits in primary care, providers rarely perform a comprehensive screen for frailty indicators, such as assessment of muscle weakness or slowness of gait, due to growing administrative burden limiting patient contact time (12, 13). Physical therapists (PTs) are ideally positioned to identify frailty in geriatric healthcare settings, because they are often the first-line providers for treatment of frailty-associated functional impairments such as slowness of gait, fatigue, and weakness. However, the potential impact and contribution of PTs to the public health aspect of frailty has not been fully realized, which leads to a gap in understanding of how and when to utilize physical therapy services for frail older adults. Therefore, the purpose of this publication is to highlight the potential role and value of PTs in promoting population health, reducing healthcare costs, and improving outcomes for frail older adults (Figure 1).


Improving Population Health

Improving the health of the frail older adult population, as part of the Triple Aim, can be achieved through early identification and timely treatment of unmet, yet addressable, clinical needs (9, 14). Currently there is a paucity of population analyses to characterize frail older adults and subsequently identify high-risk patients, track population outcomes over time, and promote longitudinal monitoring of cost or utilization trends (14, 15). Standardizing the screening tools for frailty used by PTs and other healthcare providers could be an impactful first step towards gathering quality data to identify high-risk patients and populate outcomes databases for clinical, research, and policy analyses. For example, the physical therapy profession is developing a Physical Therapy Outcomes Registry, which focuses on enhancing patient care and improving practice through objective demonstration of the value of physical therapy services (16). Physical therapy practices can also contract with companies such as Focus on Therapeutic Outcomes Inc.® (FOTO) for data management and analysis (17). Additionally, on a wider interdisciplinary scale, sections of the National Institutes of Health have begun to promote standardized data collection across research projects and data sharing to promote greater collaboration through larger data sets (18). These initiatives could lead to greater accuracy and earlier identification of pre-frail or frail patients at the highest risk for adverse events and increased healthcare utilization. Large data collection can also help researchers and healthsystems identify characteristics responders to interventions designed to prevent, treat, or reverse frailty, which would more accurately characterize who to target with interventions.  Additionally, a database consisting of clinical outcomes and frailty assessments may enable providers, clinical researchers, and policy makers to study cost-effectiveness of physical therapy interventions for frail older adults and, subsequently, inform health policy regarding reimbursement and payment reform across healthcare settings.



Figure 1 Schematic regarding the role of physical therapists in achieving the Triple Aim with respect to the treatment and management of the frail older adult

Figure 1
Schematic regarding the role of physical therapists in achieving the Triple Aim with respect to the treatment and management of the frail older adult


Unmet needs born out of lack of screening and early identification lead to risk for and greater prevalence of adverse events in the frail older adult population.  Thus, initiating timely intervention to reduce or reverse frailty severity for these older adults is critical. PTs, as trained exercise interventionists, are ideally positioned to improve population health through delivery of safe and evidence-based rehabilitation for older adults with frailty. Consequently, PTs may be the first providers to recognize this risk and can intervene early through physical therapy interventions and referrals to other healthcare providers.


Reducing Per Capita Costs

Reducing per capita costs of high-quality care is a second essential step to achieving the Triple Aim for the frail older adult population. PTs can help achieve this step through timely initiation of exercise interventions and development of preventative programs (9, 14). Physical therapy research and clinical data could help optimize identification and initiation of physical therapy interventions to improve physical function, and to initiate referrals to other healthcare providers. Physical function is a robust risk factor for hospitalization in older adult populations (19). In fact, previous studies have shown that low physical function is associated with greater risk for hospitalization and death (20). Thus, including physical therapy services in the care of frail older adults has the potential to reduce costs, because risk factors for costly rehospitalization and institutionalization – such as gait speed, weakness, and dependence with activities of daily living (21, 22) – are potentially modifiable through physical therapy interventions (23, 24).
Furthermore, the early identification of frailty provides opportunities for prevention efforts, including population and patient-level education, motivational interviewing, and an emphasis on patient self-management that can in turn reduce costs (23). PTs can provide patient education on the safe use of assistive devices, equipment for a fall-proof home, appropriate exercise prescription, and recommendations for appropriate home health care assistance given the extent of mobility or activities of daily living limitations (23). PTs can also engage the patient and caregivers in problem-solving self-management needs. For example, PTs can teach patients and caregivers how to monitor and report mobility-related warning signs such as declines in gait speed or new impairments in daily activities (23). Patient self-monitoring, early detection of new or worsening impairments, and communication with the PTs or other providers of the interdisciplinary care team can potentially mitigate costly, avoidable rehospitalizations and institutionalization.


Optimizing Patient Experience

Optimizing the patient experience is the third critical component of the Triple Aim and can be achieved through PT-initiated programs to support wellness while aging. Additionally, PTs often work collaboratively with other healthcare disciplines to develop coordinated, interdisciplinary, patient-centered care plans for frail older adults, which can include wellness components and a holistic approach to care. Patient experiences and outcomes are better when healthcare teams work together (23, 25-29), which may in turn decrease healthcare utilization (23, 30). Perhaps the quintessential role of PTs in optimizing patient experiences is through promotion of “aging in place.” To achieve this, PTs can work with patients and caregivers to develop health and wellness educational materials to improve home safety and maintain independence; these materials could include strategies for maintaining function, improving physical activity, and reducing falls risk for frail older adults. Although integrating wellness into physical therapy to improve QOL is a growing area of the profession, it is currently not the standard of care and may be a gap in physical therapy curricula and reimbursement policies. Maintaining QOL for frail older adults is important to the patient as well as the health system’s perspective. For example adverse, costly, and oftentimes life-changing outcomes in older adults who are frail—such as mortality, falls, hospitalization, and institutionalization–are intricately linked with QOL (7, 31-35). Numerous studies have shown an inverse relationship between frailty and QOL at a single point in time, with a faster decline in QOL in those with frailty indicators (7, 31, 32). Therefore, frailty is a clear example of a condition that is conducive to a patient-centered, holistic approach to care (36) as awareness, prevention, early detection, and rapid intervention may help frail older adults “age in place” (10) with an improved QOL.


Physical Therapy Research and Initiatives through a Public Health Lens

Public Health will likely play an increasing role in achieving the Triple Aim through prevention and management of frail older adults (improve population health) to promote quality of life (optimize patient experience) at lower costs (reduce per capita costs). However, the integration and assessment of physical therapy services in this realm has not been adequately studied. Physical therapy services can potentially reduce healthcare costs when examined through a Public Health lens (37). For example, the increasing demand for high-quality, cost-saving healthcare delivery has stimulated cost-effectiveness and economic analyses of physical therapy (6) for arthritis and back pain exercise interventions; hip protector studies; and continence training (38).  However no studies have specifically looked at the cost-effectiveness of physical therapy services and outcomes in the frail older adults population. Physical therapy interventions alone may be insufficient to reverse frailty and reduce costs; however an interdisciplinary approach that includes PTs is likely a cost-effective strategy to treat frail older adults. Thus, cost-effectiveness research is greatly needed to assert the value of physical therapy in promoting optimal outcomes in the frail older adult population and subsequently achieving improved population health at lower healthcare costs, while also enhancing patient experiences.
Traditionally, physical therapy knowledge has been built on quantitative studies, with a paucity of patient-centered research (39), which hinders the ability to assess the patient experience arm of the Triple Aim. Qualitative research in physical therapy offers the opportunity to identify novel factors and challenges to health care delivery that includes the frail patient and caregivers in the decision-making process (39). Comparative effectiveness research of existing interventions would provide a risk to benefit profile that PTs, as part of an interdisciplinary team, and patients could use to make informed health care decisions (9). The Patient Centered Outcomes Research Initiative (PCORI) has bolstered enthusiasm for investigations about informed health care decision-making. The mission of PCORI is to “[help] people make informed healthcare decisions, and [improve] healthcare delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community” (40). Physical therapists have been awarded more than 28 million U.S. dollars of PCORI funding to analyze outcomes in real-world settings, with patient involvement early in the process (41). Nonetheless, a notable gap remains to involve frail older adults in the clinical decision process, which likely impacts patient experiences and subsequent outcomes across the spectrum of healthcare settings.



In the context of interdisciplinary healthcare teams and patient-centered care approaches, understanding the value of PTs in achieving the Triple Aim for the frail older adult population is important to the future of healthcare (Figure 1). However, a major gap exists in understanding the potential cost-savings of physical therapy services, as well as the role of PTs in improving patient experiences and outcomes in the frail older adult population. Overall, the use of rehabilitative approaches to care for the frail older adult population has strong potential to improve functional status and QOL, while concurrently reducing rates of disability, rehospitalization, institutionalization, and healthcare costs.


Funding: This research was funded in part by the Florence P. Kendall Doctoral Scholarship and the Promotion of Doctoral Studies I from the Foundation for Physical Therapy; the Fellowship for Geriatric Research from the Academy of Geriatric Physical Therapy; the Integrative Physical of Aging Training Grant T32AG000279; R25 CA160013; the University of Colorado Cancer Center the Rehabilitation Research& Development Small Projects in Rehabilitation Research I21 RX002193-01 from the U.S Department of Veteran Affairs; and the Rehabilitation Research& Development Merit Award I01 RX001978-01 from the U.S Department of Veteran Affairs. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.
Conflict of Interest Disclosure: None



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N.M. PEEL1, S.S. KUYS2,3


1. Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia; 2. Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia; 3. Allied Health Research Collaborative, Metro North Hospital and Health Service, Queensland Health, Brisbane, Queensland, Australia

Corresponding author: Dr Nancye Peel, Research Fellow, Centre for Research in Geriatric Medicine, Level 2 Building 33, Princess Alexandra Hospital, Ipswich Road, Brisbane, Queensland 4102, Australia, Ph:  +61 7 3176 7402, Fax: +61 7 3176 6945, Email: n.peel@uq.edu.au

J Frailty Aging 2013;2(1):22-26

Published online February 13 2016, http://dx.doi.org/10.14283/jfa.2013.4


Objectives: To quantify, using accelerometry, walking activity of older rehabilitation inpatients and to examine the relationship between walking activity and functional outcomes. Design: Prospective cohort study. Setting: Inpatient geriatric rehabilitation unit. Participants: Of 74 consecutive eligible patients, aged 60 years or older and able to walk independently or with assistance, 60 participants (32 males, 28 females) with a mean (SD) length of stay of 37 (26) days completed the study. Intervention Measures: An accelerometer was worn in daytime hours from study recruitment until discharge to monitor daily walking minutes. Results: On study entry, patients spent a median (IQR) of 33 (20 to 48) minutes (7%) of the daily monitored eight hour period walking. By discharge, this had increased to 43 (30 to 56) minutes (9%) (p< 0.001). Average daily walking activity over the week prior to discharge correlated with change in gait speed from admission to discharge (p<0.05). Walking activity prior to discharge was significantly different (p<0.05) between the slowest gait speed group (≤0.4 m/s) and the fastest gait speed group (≥0.8 m/s). Those with discharge gait speeds ≥0.8 m/s (associated with ability to be ambulant in the community) had median (IQR) daily walking times at discharge of 51 (33 to 78) minutes. Conclusion: Activity monitoring has the potential to assist clinicians and patients set goals around activity levels to achieve better outcomes.

Key words: Ambulatory monitoring, geriatric assessment, rehabilitation.



For frail older people, low levels of mobility during hospitalization are associated with functional decline and deconditioning, leading to increased length of stay, post discharge readmission or transfer to permanent residential care (1, 2). Results of activity monitoring of older people in acute care (3) and post-acute rehabilitation settings (4-6) have shown that activity levels in older people are low, with the majority of time spent sitting or lying- activities that contribute little to rehabilitation (5).

Activity prescription could potentially improve outcomes for older people in rehabilitation settings (7, 8). However, there are no clear guidelines for recommended levels of activity and there is little evidence about the relationship between mobility levels (time spent walking) and functional outcomes of rehabilitation (7, 9). With the recent development in accelerometry it is now possible to continuously monitor and objectively quantify ambulatory activity to assist clinical practice in promoting and managing activity in rehabilitation settings (7, 10).

The purpose of this study was to quantify, using accelerometry, the level of activity of older patients over the course of their rehabilitation and to examine the relationship between walking activity and functional outcomes at discharge. We hypothesised that the level of activity of older patients would be low during their rehabilitation and that higher activity levels at discharge would be associated with better functional outcomes.



Study design and setting

A prospective cohort study was conducted in a 74 bed geriatric rehabilitation unit at a tertiary hospital in Queensland, Australia. Approval for the study was obtained from the institutional human research ethics committee.


Eligible patients were 60 years or older and able to walk independently or with assistance or supervision of clinical staff. Excluded were patients who were unable to give informed consent to participate, as well as those not capable of bipedal locomotion such as lower limb amputees. Patients were recruited over the period February 2008 to December 2009. Of 74 patients identified as eligible, 60 participants (32 males, 28 females) completed the study, nine withdrew and five declined to participate. Participants underwent individualised rehabilitation programs targeting specific cognitive and physical impairments and activity limitations prescribed by their respective multidisciplinary rehabilitation team and frequently included balance and mobility retraining and restoration of functional ability. While walking outside of therapy sessions was encouraged, it was not specifically prescribed by the treating team.


Six triaxial accelerometer devices were available in this study. Participants wore the accelerometer over their right hip, using an adjustable belt around their waist. The device was worn during daytime hours, except when showering, until discharge from rehabilitation. A detailed record of the times when devices were applied and removed from participants was recorded.


Activity level was measured as daily walking time, calculated from accelerometry signals using previously validated algorithms developed on a similar geriatric inpatient population (9).  Outcome measures routinely collected in the Geriatric Rehabilitation Unit include the Functional Independence Measure (FIM) (11), Timed up and go test (TUG) (12) and gait speed (13). The FIM is used in rehabilitation settings to assess the level of assistance required during the performance of motor tasks, self-care activities, communication, and cognitive tasks. The FIM™ instrument comprises 18 items each assessed against a seven point ordinal scale, with total scores ranging from 18 to 126. The items can be divided into a motor component, FIM (M) of 13 items (range 13 to 91) and a cognitive component, FIM (C), of 5 items (range 5 to 35) with higher scores indicating greater level of independent activity. The TUG documents the time in seconds that is required to rise from a standard arm chair, walk to a line on the floor three meters away, turn, return, and sit down again (12). Gait speed calculated as metres/second (m/s) was assessed over 10 metres with a moving start and finish. Patients used their usual walking aid and were instructed to walk at a comfortable pace. The first two metres and last two metres were not included in the measurement to allow for acceleration and deceleration (14, 15). Those unable to complete the test were allocated a gait speed of 0 m/s. Data were collected within 72 hours of admission and discharge by the treating therapist.

Patient details included age, gender, admission and discharge dates, diagnosis and destination.


Average walking time (minutes) was calculated for weekdays, weekends and for the entire week for each week until discharge from rehabilitation.  Average daily walking time (minutes) was calculated for full (8-hour) days of data collection in the week following recruitment to the study and in the week prior to exit from the study. For those with a length of stay of less than one week, the first and last daily walking times were used. Depending on the distribution of the data, parametric or nonparametric paired sample tests were used to determine if average walking time changed between admission and discharge and if there was a difference between walking times during weekdays compared with the weekend.  Correlation statistics, parametric and nonparametric as required, were used to determine the relationship between average walking time over the last week prior to discharge with change in gait speed, TUG and the FIM measures, as well as length of stay over the rehabilitation period.

The cohort was divided into three groups based on discharge gait speed: ≤0.4m/s; >0.4m/s to <0.8m/s; and ≥ 0.8 m/s. Gait speed lower than 0.4m/s identifies those at risk of further functional decline and reflects an inability to meet self care needs, both basic and instrumental activities of daily living (16, 17). A gait speed of less than 0.8m/s has been used to predict those at risk of mobility and disability within two years (16) and is associated with limited capacity for community ambulation (17), while a gait speed of 0.8m/s and better is associated with ability to be ambulant in the community (17). Kruskal-Wallis Test was used to calculate between group differences in average walking time over the last week prior to discharge with discharge gait speed group. Post-hoc analyses were planned using Mann-Whitney test for paired samples to determine differences between the slowest and fastest gait speed groups. Data were analysed using Statistical Package for the Social Sciences Version 18.0 (SPSS Inc, Chicago, Illinois).


Sixty participants (32 males, 28 females) were recruited to this study. Participant characteristics are presented in Table 1. Fifty-four (90%) participants wore the accelerometer until discharge. Reasons for ceasing to wear the accelerometer prior to discharge were patient request (3) and medical illness (3). The majority (88%) were discharged home, while three were discharged to supported care accommodation, and four were transferred to acute or palliative care.


Table 1 Participants’ characteristics

* pain, pulmonary, other disabling impairment

Only full days in which eight hours of accelerometry data were collected were included in the analysis. Over the study period, accelerometers were worn on 1122 days (86%), with full day data collected on 807 (72%) of these days. Three participants who had fewer than three days of data were excluded from the study, leaving 57 participants included in the analysis.

Tests of normality indicated that the data on walking time were not normally distributed so that non-parametric tests were used in analysis. Median (IQR) for daily walking time for the first week following recruitment to the study was 33 (20 to 48) minutes. This had significantly increased to 43 (30 to 56) minutes of daily walking by discharge (Wilcoxon Signed Ranks Test; Z=-3.6; p< 0.001). Walking time on weekdays and weekends was compared for patients with data on both weekday and weekend. For 96 paired observations there was a significant difference between the median (IQR) daily walking time for weekdays, 39 (27 to 56) minutes, compared with weekends, 31 (19 to 50) minutes (Wilcoxon Signed Ranks Test; Z=-4.9; p<0.001).

Functional performance measures on admission and discharge from rehabilitation are presented in Table 2. Average daily walking activity over the last week prior to discharge significantly correlated with change in gait speed (Spearman’s rho=0.290, p<0.05) and change in FIM (Cognition) (Spearman’s rho=0.274, p<0.05) from admission to discharge, and negatively with length of stay (Spearman’s rho= -0.283, p<0.05). The median (IQR) walking time at discharge was 29 (15 to 51) minutes for those with discharge gait speeds ≤0.4 m/s; 43 (32 to 66) minutes for discharge gait speed >0.4 and <0.8 m/s; and 51 (33 to 78) minutes for discharge gait speeds ≥ 0.8 m/s. Non parametric tests for independent samples for between group differences were not significant (Kruskal-Wallis Test; chi-square=4.3; p=0.12), but the difference between the slowest gait speed group (≤0.4 m/s) and the fastest gait speed group (≥0.8 m/s) was significant (Mann-Whitney Test; Z=-2.0; p<0.05).

Table 2 Performance measures at admission and discharge and change between admission and discharge

a. Wilcoxon signed rank tests were used to determine whether change in measures between admission and discharge were significant; b. Correlation (Spearman’s rho) tests were used to determine the relationship between walking activity at discharge and change in functional performance measures; * p<0.05; † p<0.001


This study is one of the few studies to objectively measure activity levels across the duration of post-acute care in older patients admitted to a geriatric rehabilitation unit with a range of diagnoses. Previous studies in this setting have shown patients spent an average of less than 10% of their time in upright activities during the monitored period (4-6).   Our study confirmed that activity levels are low. On entry to the study, patients who were able to mobilise with or without assistance spent 7% of the daily monitored eight hour period walking. By discharge, this had increased to 9%. The amount of ‘uptime’ in older rehabilitation inpatients has been found to be considerably less than the daily ‘uptime’ recorded in age and gender matched community groups (5, 6).  Since the aim of rehabilitation is restoration of functional mobility for daily living it would appear that the level of walking activity recorded at discharge would be insufficient to sustain independent functioning in the community for the majority of patients in our study, who were discharged home.

The association found in this study between activity levels at discharge and improved functional outcomes, as well as reduced length of stay was significant, but further subclassification depends on other subtleties in metabolic capacities, such as the ability to use various weak (18). The association between higher levels of walking activity in the last week prior to discharge with reduced length of stay is not unexpected, as it is feasible that the amount of walking a patient does would be used as an indicator of readiness for discharge. The relationship of rehabilitation activity levels with FIM (Cognition) has not previously been reported, although physical activity (walking) has been shown to be associated with cognitive performance in later life (19).

Walking activity was also found to be related to gains in gait speed over the duration of rehabilitation. Gait speed has been shown to be a powerful predictor of survival, disability, hospitalisation, institutionalisation, dementia and falls (20) and has been described as the ‘sixth vital sign’ to provide a relevant functional perspective on health status (17). An improvement in gait speed is a good indicator of the effectiveness of a treatment or rehabilitation program (20). While the causal direction of the association between walking activity and gait speed warrants further exploration, it would seem intuitive that prescribing an increase in walking time in rehabilitation would improve gait speeds. In agreement with a recent study (21), the results of the research reported here suggest that increased walking activity can improve gait speed.

There are several limitations to the study. The participants, although typical of geriatric rehabilitation units in Australia (22), were not homogeneous with respect to diagnosis, which together with age, gender and other co-morbidities, is likely to have an influence on rehabilitation outcomes such as gait speed (23). In addition, those with a shorter length of stay may have received less rehabilitation intervention or have been more mobile; potentially influencing our study findings. Although the sample size of 60 participants is large in comparison with other studies measuring activity levels of older rehabilitation in-patients (4-6, 8), larger sample sizes would be required to adjust for confounders such as age, gender, co-morbidities, mobility status at admission, and length of stay likely to influence the relationship between walking time and rehabilitation outcomes.  Another limitation was that there was no follow-up to determine if the relationship between walking activity and post discharge functional outcomes was maintained.

Participants were categorised according to their discharge gait speed measured during a ten metre walk test with a moving start; anticipating that those with faster gait speeds would be more active. The cut-points for the categories were defined on the basis of gait speed tests performed using different methodologies. The use of a different walking distance or a moving start for example, may influence the measured gait speed (14, 15); potentially resulting in the misclassification of some of our participants.

Unlike previous studies, however, this pilot study demonstrated the feasibility of continuous monitoring of a large sample of older patients to show trends in activity across the duration of their rehabilitation. The provision of accurate feedback may prove to be highly motivating for patients participating in rehabilitation and is currently being tested in a randomised controlled trial (ACTRN12611000034932, Australian New Zealand Clinical Trials Registry).


Currently there are no recommended guidelines for physical activity levels for inpatients undergoing rehabilitation. Clinicians want to know how much activity to prescribe to patients in order to reach rehabilitation goals of community participation and functional recovery. This study would suggest that to achieve community ambulation levels associated with better health outcomes, patients should be encouraged to increase their level of daily walking activity.

Acknowledgements: The authors acknowledge the doctoral research work of Vivian Cheung in developing and testing algorithms for the accelerometers used in this study for activity monitoring.

Conflict of Interest Statement: The authors declare that there is no conflict of interest. The accelerometer devices used in this study were triaxial ALIVE Heart and Activity Monitors leased from Alive Technologies Pty Ltd., Ashmore, Queensland 4214, Australia. Technical assistance for the development of algorithms from the accelerometer devices was provided by the Commonwealth Scientific and Industrial Research Organisation (CSIRO). The suppliers had no influence on the results obtained in this study.

Author contributions: Study concept and design: NMP, SSK. Data analysis, interpretation: NMP, SSK. Preparation of manuscript: NMP, SSK.

Financial Disclosure: We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated.

Financial Support: Author NP was supported by an Early Career Research Grant from The University of Queensland to conduct this research.



1.    Lakhan P, Jones M, Wilson A, Courtney M, Hirdes J, Gray LC. A prospective cohort study of geriatric syndromes among older medical patients admitted to acute care hospitals. J Am Geriatr Soc 2011;59(11):2001-2008.
2.    Mudge AM, O’Rourke P, Denaro CP. Timing and risk factors for functional changes associated with medical hospitalization in older patients. J Gerontol A Biol Sci Med Sci 2010; 65(8):866-872.
3.    Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc 2009;57(9):1660-1665.
4.    Patterson F, Blair V, Currie A, Reid W. An investigation into activity levels of older people on a rehabilitation ward: an observational study. Physiotherapy  2005;91(1):28-34.
5.    Smith P, Galea M, Woodward M, Said C, Dorevitch M. Physical activity by elderly patients undergoing inpatient rehabilitation is low: an observational study. Aust J Physiother 2008;54(3):209-213.
6.    Bernhardt J, Borschmann K, Crock D, Hill K, McGann A, DeGori M. Stand up and be counted: measuring time spent upright after hip fracture and comparison with community dwelling older people. Physiotherapy 2005;91(4):215-222.
7.    Dakin LE, Gray LC, Peel NM, Salih SA, Cheung VH. Promoting walking amongst older patients in rehabilitation: are accelerometers the answer? J Nutr Health Aging 2010;14(10):863-865.
8.    Talkowski JB, Lenze EJ, Munin MC, Harrison C, Brach JS. Patient participation and physical activity during rehabilitation and future functional outcomes in patients after hip fracture. Arch Phys Med Rehabil 2009;90(4):618-622.
9.    Dakin L, Peel NM. Effect of accelerometry on the functional mobility of older rehabilitation inpatients as measured by functional independence measure — locomotion (FIM) gain: A retrospective matched cohort study. J Nutr Health Aging 2011;15(5):382-386.
10.     Cheung VH, Gray L, Karunanithi M. Review of accelerometry for determining daily activity among elderly patients. Arch Phys Med Rehabil  2011;92(6):998-1014.
11.    Kidd D, Stewart G, Baldry J, Johnson J, Rossiter D, Petruckevitch, A et al. The Functional Independence Measure: a comparative validity and reliability study. Disabil Rehabil 1995;17(1):10-14.
12.     Podsiadlo D, Richardson S. The timed «Up & Go»: a test of basic functional mobility for frail elderly persons. J Amer Geriatr Soc 1991;39(2):142-148.
13.     Kuys SS, Bew PG, Lynch MR, Morrison G, Brauer SG. Measures of activity limitation on admission to rehabilitation after stroke predict walking speed at discharge: an observational study. Aust J Physiother 2009;55(4):265-268.
14.     Graham JE, Ostir GV, Fisher SR, Ottenbacher KJ. Assessing walking speed in clinical research: a systematic review. J Evaluat Clin Prac 2008;14:552-562.
15.    Graham JE, Ostir GV, Kuo YF, Fisher SR, Ottenbacher KJ. Relationship between test methodology and mean velocity in timed walk tests: a review. Arch Phys Med Rehabil 2008;89(5): 865-872.
16.    Abellan van Kan G, Rolland Y, Andrieu S, Bauer J, Beauchet O, Bonnefoy M, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people: An International Academy on Nutrition and Aging (IANA) Task Force. J Nutr Health Aging  2009;13(10):881-889.
17.    Fritz S, Lusardi M. White paper: «walking speed: the sixth vital sign» J Geriatr Phys Ther 2009;32(2):46-49.
18.    De Vaus DA. Analyzing Social Science Data. 2002. SAGE, London.
19.    Yaffe K, Barnes D, Nevitt M, Lui LY, Covinsky K. A prospective study of physical activity and cognitive decline in elderly women: women who walk. Arch Intern Med 2001;161(14):1703-1708.
20.     Studenski S. Bradypedia: is gait speed ready for clinical use? J Nutr Health Aging 2009;13(10):878-880.
21.    Yamada M, Mori S, Nishiguchi S, Kajiwara Y, Yoshimura K, Sonoda T, et al. Pedometer-based behavioural change program can improve dependency in sedentary older adults: a randomised controlled trial. J Frailty Aging 2012;1(1):39-44.
22.    Haines T, Kuys SS, Morrison G, Clarke J, Bew P, McPhail S. Development and validation of the balance outcome measure for elder rehabilitation. Arch Phys Med Rehabil. 2007;88(12):1614-1621.
23.     Peel NM, Kuys SS, Klein K. Gait speed as a measure in geriatric assessment in clinical settings: a systematic review. J Gerontol A Biol Sci Med Sci 2012; doi: 10.1093/gerona/gls174.




1. Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland; 2. The Royal Hospital Donnybrook, Dublin, Ireland

Corresponding author: Dr. Roman Romero-Ortuno, Department of Medical Gerontology, Trinity College Dublin, Trinity Centre for Health Sciences, St James’s Hospital, James’s Street, Dublin 8, Ireland, Email: romeror@tcd.ie, Telephone: +353 1 896 3555, Fax: +353 1 896 3407

J Frailty Aging 2014;3(4):234-237
Published online January 12, 2015, http://dx.doi.org/10.14283/jfa.2014.30


We assessed the correlations of the Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI on admission: non-frail, pre-frail, frail) with the outcomes of a Short-term Post-Acute Rehabilitative Care programme (N=172 admissions over one-year period, 95 of which were frail). SHARE-FI correlated with age (non-frail: mean 79.2 years; frail: 83.6; P<0.001). Adjusting for age, SHARE-FI correlated with longer length of stay (non-frail: median 30 days; frail: 42; P=0.047), higher rate of emergency transfer to acute hospital (non-frail: 2.4%; frail: 21.1%; P=0.004), and lower home discharge rate (non-frail: 97.6%; frail: 81.9%; P=0.009). While frailty correlated with more disability on admission and discharge, there was no statistically significant difference in Barthel Index (BI) improvement across frailty categories (all groups had median BI improvement of ≥2 points, P=0.247). The post-acute rehabilitation of the frail is worthwhile but requires more time and access to acute hospital facilities.

Key words: Frail elderly, rehabilitation, observational study, outcomes assessment, Ireland.


Multidisciplinary rehabilitation programmes in post-acute settings can positively influence the pace and extent of return of function after an acute hospital admission (1).

The population of older people is heterogeneous (2), and a subgroup of older in-patients who may benefit from post-acute rehabilitation are frail. Frailty in older adults is characterized by a cumulative decline in many physiological systems, which results in poor resolution of homoeostasis after stressor events and confers vulnerability to adverse outcomes (3).

In recent years, progress has been made in operational definitions of frailty that are suitable for research and clinical purposes. Two popular approaches are the accumulation of deficits and the frailty phenotype (3). Although those measures have been extensively validated in population-based samples as regards incident disability, hospitalization, institutionalization and mortality (4), very few studies have focused on frailty assessment tools as predictors of rehabilitation outcomes in older adults. In an acute geriatric rehabilitation ward, a previous study found that frailty (defined in terms of accumulation of deficits) correlated significantly with length of stay and was a predictor of poor functional gain during rehabilitation (5). However, another study showed that a programme of rehabilitation after hospitalization may confer clinically significant and long-lasting functional gains in frail older adults (6).

From the literature on frailty and rehabilitation, one cannot assume that the frail are “destined to fail”. To our knowledge, there were no studies using a phenotypic measure of frailty in a post-acute rehabilitation setting, and our aim was to fill this gap.



The Royal Hospital Donnybrook (RHD) in Dublin is a 150- bed hospital which provides care for patients requiring rehabilitation, complex continuing care and day hospital services. It is located 2 miles from its associated acute tertiary hospital, St. Vincent’s University Hospital (SVUH).

Model of rehabilitative care

The Short-term Post Acute Rehabilitative Care (SPARC) Unit is a 22 bed rehabilitation unit. It provides specialist geriatrician-led multidisciplinary input for patients aged 65 years and over who are medically stable and fit for discharge from acute hospital care. Patients are referred to SPARC from any medical or surgical team in SVUH. All patients have a preadmission senior nursing or medical assessment. Further information on SPARC is available on http://www.rhd.ie/index. php/what-we-do/sparc.


We included all first admissions to SPARC between January and December 2013 (N=172).


We retrospectively collected information on patient demographics (i.e. age, gender, living alone), referring service in SVUH, and main diagnosis requiring rehabilitation. Cognitive impairment was defined as a Mini-Mental State Examination (MMSE) score of <23 points (7) or an Addenbrooke’s Cognitive Examination (ACE-R) score of <82 points (8), on admission to SPARC.

Frailty status on admission was measured with the Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI) (9). SHARE-FI is a simple frailty screening tool based on modified phenotypic criteria:

  • “Too little energy to do the things you wanted to do”.
  • “Diminution in desire for food” or “eating less than usual”.
  • Low grip strength (measured with a handheld dynamometer).
  • Difficulty “walking 100 metres” or “climbing one flight of stairs without resting”.
  • Infrequent engagement in activities like “gardening, cleaning the car or doing a walk”.

SHARE-FI has been validated against commonly used frailty scales in their ability to predict all-cause mortality (10) and as a predictor of incident disability (11). Levels of frailty (i.e. non- frail, pre-frail, frail) were measured using the published gender- specific online calculators (http://www.biomedcentral.com/1471-2318/10/57/additional).

We retrospectively measured the following rehabilitation outcomes: length of stay (LOS) in SPARC (days), emergency transfer to the acute hospital (SVUH) due to medical destabilization during rehabilitation, and change in Barthel Index (BI) of basic activities of daily living (i.e. discharge BI minus admission BI). The 10-item BI scale, score range 0–20 (higher scores indicating lower disability), was used (12). Those who were transferred to SVUH due to medical destabilization but did not return to SPARC did not have a discharge BI. We recorded the discharge destination for all those who were discharged from SPARC following completion of the rehabilitation programme.


This retrospective observational study was carried out in compliance with the clinical audit standards in The Royal Hospital Donnybrook.

Statistical analyses

Data was analysed using IBM SPSS (version 20). Descriptive data are given as mean with standard deviation (SD), median with interquartile range (IQR), or percentages (%). The presence of gradients across frailty categories was assessed with the Chi-square test for trend (dichotomous variables) or the two-sided Spearman’s correlation coefficient (continuous variables). To assess these gradients controlling for age, we used multivariate binary logistic or multiple linear regression, respectively. P < 0.05 was considered statistically significant.


Between January–December 2013, there were 172 first admissions to SPARC. Their mean age was 81.9 years (SD 7.3, range 65–100), and 65.1% were women. In the total sample, the proportion of living alone was 50.9%.

Of the 172 first admissions, 91 (52.9%) were referred by the medical team, and 62 (36.0%) by the orthopaedic team. The most common main diagnosis was fracture or fall (103 patients). The frequencies of other diagnoses were as follows: stroke: 5.3%, post-operative: 2.9%, respiratory: 9.4%, cardiac: 4.7%, and other: 17.5%. Overall, the prevalence of cognitive impairment was 30.8% (N=53). Of N=172, 168 (97.7%) had SHARE-FI measured on admission. Of N=168, 41 (24.4%) were non-frail, 32 (19.0%) were pre-frail, and 95 (56.5%) were frail.

Overall, 25 patients (14.5%) required an emergency transfer to the acute hospital during their rehabilitation. Of them, 17 did not return to SPARC and therefore had no discharge BI available. The overall mean LOS in SPARC was 37.5 days (SD 20.3) (median of 34.0 days). The median BI on admission was 14, and the median BI on discharge was 17 (median improvement of 3 BI points). Figure 1 shows the buy cialis low price, extra discount! cialis canada cheap cialis tablets mean BI on admission and discharge (with 95% confidence intervals) by SHARE-FI categories. Of the 155 patients who were discharged from SPARC following completion of the rehabilitation programme, 148 (95.5%) were discharged home.

Table 1 shows the statistical gradients across SHARE-FI frailty categories. Increasing frailty correlated if you would like to receive even more information relating to baclofen kindly go to pharmacy lookup. can you buy baclofen over the counter in mexico with advancing age (non-frail: mean 79.2 years; frail: mean 83.6 years; P<0.001). After adjusting for age, SHARE-FI correlated with longer LOS (non-frail: median 30 days; frail: median 42 days; P=0.047), higher rate of emergency transfer to acute hospital (non-frail: 2.4%; frail: 21.1%; P=0.004), and lower home discharge rate (non-frail: 97.6%; frail: 81.9%; P=0.009). While frailty correlated with more disability on admission and discharge, there was no statistically significant difference in absolute BI improvement across frailty categories (all frailty groups had median BI improvement of at least 2 points, P=0.247).

Table 1: SHARE-FI correlates in the SPARC sample

* 2-sided Spearman’s rho correlation coefficient; † Chi-square for trend test; ‡ Age adjustment based on multivariate binary logistic regression; § Age adjustment based on multiple linear regression 


Figure 1: Barthel Index (BI) on admission and discharge by SHARE-FI categories. Mean values are presented between upper and lower 95% confidence intervals (CI) for the means. (Number of BI on admission: 41 non-frail, 32 pre-frail, and 95 frail. Number of BI on discharge: 41 non-frail, 31 pre-frail, and 82 frail). Circles, triangles, and rectangles represent mean values for non-frail, pre- frail, and frail, respectively. Lines indicate 95% confidence intervals



The aim of this retrospective observational study was to assess the correlations of a routinely collected phenotypic measure of frailty (SHARE-FI on admission) with the clinical outcomes of an off-site post-acute rehabilitation program. Only 24.4% of patients were non-frail on admission, with the majority (56.5%) being frail and further 19.0% being pre-frail.

Thus, frailty was well represented in SPARC. Frail rehabilitation patients were older and more dependent at baseline and on discharge; they rehabilitated more slowly and had more acute medical complications requiring emergency transfer to the acute hospital, but their absolute improvement in dependency score (i.e. BI) was comparable to non-frail patients, with a home discharge rate lower than non-frail patients but still superior to 80%.

In an acute geriatric rehabilitation ward, a previous study found that frailty (defined in terms of accumulation of deficits) correlated significantly with LOS and was a predictor of poor functional gain during rehabilitation (5). Based on our results, we would agree with the former observation but not with the latter, as all frailty groups in our sample experienced a BI increase beyond the clinically important difference. Indeed, a change of ≈2 points in BI (scored 0-20) is meaningful and beyond measurement error (13).

A limitation is that 17 of the 25 patients who required an emergency transfer to the acute hospital did not return to SPARC and therefore had no discharge BI available. As Table 1 shows, those patients were more likely to be frail (P=0.027); but unfortunately their data could not be captured in this study.

Despite the fact that all patients admitted to SPARC had a preadmission senior nursing or medical assessment to ensure that they were medically stable, the frail had a higher medical decompensation risk and we interpret that in the light of their higher medical complexity and intrinsic vulnerability, which is a core feature of frailty (3).

Our results with SHARE-FI contrast with those of a previous study that used the Edmonton Frailty Scale (EFS), which found that the EFS was not a useful predictor of rehabilitation and discharge outcomes for older people in subacute care, and concluded that alternative frailty measures may be more suitable than the EFS for patients in a subacute setting (14).

In conclusion, the post-acute rehabilitation of frail older people is worthwhile for the majority but requires more time and access to acute facilities. Thus, we agree that frail older patients should be routinely screened for rehabilitation potential (15).


Acknowledgements: We wish to acknowledge all clinical and non-clinical staff at the Royal Hospital Donnybrook for their continued dedication and enthusiasm.

Funding: No funding was required.

Conflict of Interest: None.



1. Ward A, Gutenbrunner C, Giustini A, et al. A position paper on Physical & Rehabilitation Medicine programmes in post-acute settings. Union of European Medical Specialists Section of Physical & Rehabilitation Medicine (in conjunction with the European Society of Physical & Rehabilitation Medicine). J Rehabil Med 2012;44:289-298.

2. Lloyd-Sherlock P, McKee M, Ebrahim S, et al. Population ageing and health. Lancet 2012;379:1295-1296.

3. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet 2013;381:752-762.

4. Bouillon K, Kivimaki M, Hamer M, et al. Measures of frailty in population-based studies: an overview. BMC Geriatr 2013;13:64.

5. Singh I, Gallacher J, Davis K, Johansen A, Eeles E, Hubbard RE. Predictors of adverse outcomes on an acute geriatric rehabilitation ward. Age Ageing 2012;41:242-246.

6. Timonen L, Rantanen T, Ryynanen OP, Taimela S, Timonen TE, Sulkava R. A randomized controlled trial of rehabilitation after hospitalization in frail older women: effects on strength, balance and mobility. Scand J Med Sci Sports 2002;12:186-192.

7. Cullen B, Fahy S, Cunningham CJ, et al. Screening for dementia in an Irish community sample using MMSE: a comparison of norm-adjusted versus fixed cut-points. Int J Geriatr Psychiatry 2005;20:371-376.

8. Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. The Addenbrooke’s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006;21:1078- 1085.

9. Romero-Ortuno R, Walsh CD, Lawlor BA, Kenny RA. A frailty instrument for primary care: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE). BMC Geriatr 2010;10:57.

10. Theou O, Brothers TD, Mitnitski A, Rockwood K. Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. J Am Geriatr Soc 2013;61:1537-1551.

11. Romero-Ortuno R, O’Shea D, Kenny RA. The SHARE frailty instrument for primary care predicts incident disability in a European population- based sample. Qual Prim Care 2011;19:301-309.

12. Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud 1988;10:61-63.

13. Hsieh YW, Wang CH, Wu SC, Chen PC, Sheu CF, Hsieh CL. Establishing the minimal clinically important difference of the Barthel Index in stroke patients. Neurorehabil Neural Repair 2007;21:233-238.

14. Haley MN, Wells YD, Holland AE. Relationship between frailty and discharge outcomes in subacute care. Aust Health Rev 2014;38:25-29.

15. Wells JL, Seabrook JA, Stolee P, Borrie MJ, Knoefel F. State of the art in geriatric rehabilitation. Part I: review of frailty and comprehensive geriatric assessment. Arch Phys Med Rehabil 2003;84:890-897.




Corresponding author: Hidetaka Wakabayashi, Department of Rehabilitation Medicine, Yokohama City University Medical Center, 4-57 Urafune-chou, Minami ward, Yokohama city, Japan 232-0024, Phone: +81-45-261-5656, Fax: +81-45-253-9955, E-mail: noventurenoglory@gmail.com

J Frailty Aging 2014;3(2):97-103
Published online December 8, 2014, http://dx.doi.org/10.14283/jfa.2014.8


Presbyphagia refers to age-related changes in the swallowing mechanism in the elderly associated with a frailty in swallowing. Presbyphagia is different from dysphagia. Sarcopenic dysphagia is difficulty swallowing due to sarcopenia of generalized skeletal muscles and swallowing muscles. Age-related loss of swallowing muscle mass becomes evident in the geniohyoid muscle and tongue. Elderly subjects with both sarcopenia and dysphagia may have not only disease-related dysphagia but also sarcopenic dysphagia. In cases of aspiration pneumonia, deterioration in activity-, disease-, and nutrition-related sarcopenia of generalized skeletal muscles and swallowing muscles may develop into sarcopenic dysphagia. Assessment of sarcopenic dysphagia includes evaluation of both dysphagia and sarcopenia. The 10-item Eating Assessment Tool (EAT-10) and a water test combined with pulse oximetry are useful for dysphagia screening. Assessment of the multi-factorial causes of sarcopenia including nutritional review is important, because rehabilitation of sarcopenic dysphagia differs depending on its etiology. Consensus diagnostic criteria for sarcopenic dysphagia were proposed at the 19th Annual Meeting of the Japanese Society of Dysphagia Rehabilitation. Rehabilitation for sarcopenic dysphagia includes treatment of both dysphagia and sarcopenia. The core components of dysphagia rehabilitation are oral health care, rehabilitative techniques, and food modification. The causes of adult malnutrition may also contribute to the etiology of secondary sarcopenia and sarcopenic dysphagia. Therefore, nutrition management is indispensable for sarcopenic dysphagia rehabilitation. In cases of sarcopenia with numerous complicating causes, treatment should include pharmaceutical therapies for age-related sarcopenia and comorbid chronic diseases, resistance training, early ambulation, nutrition management, protein and amino acid supplementation, and non-smoking.

Key words: Rehabilitation, malnutrition, frailty, swallowing muscle, EAT-10.



The term presbyphagia refers to age-related changes in the swallowing mechanism in the elderly (1). Presbyphagia is characterized by frailty of swallowing. Modification of swallowing related solely to aging is called primary presbyphagia, while swallowing changes due to diseases in the elderly is called secondary presbyphagia (2). Presbyphagia represents healthy swallowing in elderly subjects (3), and not dysphagia. Although the exact prevalence of presbyphagia is unknown, the number of healthy older adults who have penetration and aspiration during assessment of normal swallowing by simultaneous manometry and flexible endoscopic evaluation was 75% and 30%, respectively (4). Another study that investigated the relationship of aspiration status with tongue and handgrip strength in healthy older adults using flexible endoscopic evaluation of swallowing showed that 37% of healthy elderly were aspirators (5). These results indicate that presbyphagia is common in healthy older adults.

The term sarcopenic dysphagia refers to difficulty swallowing due to sarcopenia of generalized skeletal muscles and swallowing muscles (6, 7). In frail elderly patients with oropharyngeal dysphagia, impaired safety of deglutition and aspirations are caused mainly by delayed closure of the laryngeal vestibule (8). Impaired efficacy and residue are related mainly to weak tongue bolus propulsion forces and slow hyoid motion (8). These impairments in frail elderly patients with oropharyngeal dysphagia may be associated with sarcopenia of the tongue and suprahyoid muscles, indicating the presence of sarcopenic dysphagia. The exact prevalence of sarcopenic dysphagia is unknown. The prevalence of sarcopenia assessed by appendicular skeletal muscle mass (in kgs) divided by squared height (in meters) has been estimated to range between 13% to 24% in adults over 60 years of age, and to more than 50% in people aged 80 or older (9). The prevalence of dysphagia has been reported to range between 11.4%−38% in community-dwelling elderly individuals (10-14), and 40%−68% in nursing home residents (15-17). These findings suggest that sarcopenia and dysphagia are common in elderly subjects. Frail elderly subjects with both sarcopenia and dysphagia may have not only disease-related dysphagia caused by conditions such as stroke, brain injury, neuromuscular diseases, head and neck cancer, and connective tissue diseases, but also sarcopenic dysphagia due to sarcopenia of generalized skeletal muscles and swallowing muscles.

Dysphagia management is regarded as an important current and future public health issue in geriatric medicine and rehabilitation medicine, because presbyphagia and dysphagia are common in the elderly, and increases the risk of related complications such as aspiration pneumonia, choking, dehydration, malnutrition, and a lower quality of life following loss of the joy of eating. The first part of this review focuses on presbyphagia and sarcopenic dysphagia, followed by a summary of sarcopenic dysphagia assessment and rehabilitation for sarcopenic dysphagia.



Presbyphagia refers to age-related changes in the swallowing mechanism. Presbyphagia may present in several ways: as a lack of muscle strength complicating bolus propulsion; diminished lingual pressure, obstructing bolus driving; halting of the bolus whilst swallowing, leading to a more difficult cleansing of residues; a decline in taste and smell that makes it more difficult to initiate swallowing; difficulty in controlling the bolus from the anticipatory phase; entry of the bolus into the lower airway; and finally, lack of teeth and wearing, or not wearing complete dentures which influences chewing (17).

Age-related changes in the generation of lingual pressure is a contributing factor to presbyphagia. Healthy older individuals have significantly reduced isometric tongue pressures compared with their younger counterparts (18). A longer duration of swallowing occurs largely before the more automatic pharyngeal phase of the swallow is initiated. Co-morbidities such as xerostomia, esophageal motility, sensory changes, sarcopenia, and medications can affect swallowing function (18). Although elderly subjects with presbyphagia do not have dysphagia, they may easily develop the condition because of diminished functional reserve.



The term sarcopenia was used by Rosenberg to describe an age-related decrease in muscle mass, and originated from the Greek words sarx (flesh) and penia (loss) (19, 20). This term was applied initially to denote loss of muscle mass. In 2010, the European Working Group on Sarcopenia in Older People described sarcopenia as a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength, associated with a risk of adverse outcomes such as physical disability, poor quality of life, and death (21). In 2011, the International Working Group on Sarcopenia defined the disease as an “age-associated loss of skeletal muscle mass and function. Sarcopenia is a complex syndrome that is associated with muscle mass loss alone or in conjunction with increased fat mass. The causes of sarcopenia are multi-factorial and can include disuse, changing endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies. While cachexia may be a component of sarcopenia, the two conditions are not the same (22).” Decreased muscle strength and physical function are now also included in the definition of sarcopenia.

The European Wording Group on Sarcopenia in Older People categorized sarcopenia into two types for use in clinical practice (21). Primary sarcopenia is considered to be age- related when no other cause is evident, other than ageing itself. Secondary sarcopenia should be considered when one or more other causes are evident, such as activity-, disease-, or nutrition-related sarcopenia. The etiology of sarcopenia in the elderly is multi-factorial and therefore it may not be possible to characterize each individual as having either primary or secondary sarcopenia (21). For example, 88%-91% of elderly inpatients with hospital-associated deconditioning and the disuse syndrome are malnourished and may experience not only activity-related sarcopenia, but also age-, nutrition-, and disease-related sarcopenia (23, 24).


Sarcopenia of swallowing muscles

Sarcopenia of swallowing muscles is characterized by their loss of mass and strength associated with generalized loss of skeletal muscle mass and strength. Swallowing muscles include the intrinsic muscle of the tongue and the mimic, masticatory, suprahyoid, infrahyoid, palatal, pharyngeal, and esophageal muscles. Age-related loss of muscle mass of intrinsic muscle of the tongue and geniohyoid muscle has been studied in the elderly.

Tamura et al. (25) evaluated thickness of the central part of the tongue in the elderly using ultrasonography and showed mid-arm muscle area and age were associated independently with tongue thickness. These results indicate that tongue muscle mass is associated with generalized skeletal muscle mass and aging. In elderly subjects with sarcopenia, age-related loss of both the intrinsic muscle mass of the tongue and generalized skeletal muscle mass can occur simultaneously.

Feng et al. (26) assessed the geniohyoid muscle in healthy older adults using computed tomography. This muscle helps elevate and stabilize the hyoid bone, thus protecting the airway. A decrease in the cross-sectional area of the geniohyoid muscle has been shown to occur with increasing age, with this area being significantly smaller in aspirators compared with non- aspirators, but only in older men. Increasing fatty infiltration in the middle and posterior portions of the geniohyoid muscle was also shown to be associated with aging. These findings suggest that geniohyoid muscle atrophy may be a component of decreased swallowing safety and aspiration in older adults with presbyphagia and sarcopenic dysphagia.

Butler et al. (5) demonstrated that lower anterior and posterior isometric and swallowing tongue strength were dependent on aspiration status in healthy, older adults. Although there was no difference in handgrip strength between aspirators and non-aspirators, there was a correlation between handgrip and posterior tongue strength (5). These results indicate that tongue strength may decrease with the advent of generalized loss of skeletal muscle strength, and may be related with aspiration in healthy, older adults.


Sarcopenic dysphagia

Sarcopenic dysphagia is the condition where a subject has difficulty swallowing due to sarcopenia of the swallowing muscles and generalized skeletal muscles. The most common cause of dysphagia is stroke. In contrast, sarcopenic dysphagia is rarely diagnosed, because the concept and diagnostic criteria for the condition have not been defined. However, sarcopenic dysphagia may be common in elderly subjects with sarcopenia and dysphagia.

Kuroda et al. (6) explored the possible presence of sarcopenic dysphagia by examining the relationship between thinness and swallowing function in older Japanese adults with suspected swallowing disorders. The circumference of the mid- upper arm of the patients ranged from 11.2 to 26.2 cm (mean

19.4 ± 3.5 cm), and correlated significantly with swallowing function measured using a graded water-swallowing test. This finding suggested that swallowing impairment was related to thinness. The most likely explanation for these results is that the general reduction in lean body mass, including the swallowing muscles, is responsible for the association between mid-upper arm circumference and swallowing function, and indicates the presence of sarcopenic dysphagia (6).

One mechanism of sarcopenic dysphagia in frail, elderly subjects is an overlap between all the serious acute diseases that cause sarcopenia. Frail, elderly subjects with either age- related sarcopenia, presbyphagia, malnutrition, periodontal diseases, or chronic diseases (e.g. chronic obstructive pulmonary disease, chronic heart failure, chronic kidney disease) can eat regular or soft diets. However, the functional reserve of swallowing is limited in these frail individuals. For example, if they develop aspiration pneumonia, sarcopenia of generalized skeletal muscles and swallowing muscles rapidly deteriorate, because of activity-, nutrition-, and disease-related sarcopenia (Figure 1). Patients with aspiration pneumonia tend to be prescribed non-eating and bed rest during pneumonia treatment. Activity-related sarcopenia and disuse muscle atrophy develop during non-eating and bedridden periods, with peripheral parenteral nutrition being a common feeding route during pneumonia treatment. Nutrition-related sarcopenia may worsen during non-eating periods and peripheral parenteral nutrition, because it is difficult to satisfy energy expenditure under these conditions without oral intake and enteral nutrition. Disease-related sarcopenia may also be exacerbated by aspiration pneumonia as it is the cause of invasion and acute inflammation and results in catabolism of generalized skeletal muscles and swallowing muscles. Therefore, frail elderly subjects with presbyphagia can simultaneously experience activity-, disease-, and nutrition-related sarcopenia of generalized skeletal muscles and swallowing muscles, resulting in the development of sarcopenic dysphagia (7).

Figure 1: Aspiration pneumonia, etiology of sarcopenia, and sarcopenic dysphagia. Sarcopenic dysphagia is not only the result of aspiration pneumonia, but also an important cause of recurrent aspiration pneumonia


Assessment of sarcopenic dysphagia

Sarcopenic dysphagia assessment includes evaluation of both dysphagia and sarcopenia.


Dysphagia assessment

Screening for dysphagia is important, because presbyphagia and dysphagia are common in elderly subjects, with early detection preventing complications such as aspiration pneumonia, choking, dehydration, and malnutrition. Belafsky et al. (27) developed the 10-item Eating Assessment Tool (EAT-10, Table 1), a 10-item questionnaire for dysphagia screening, with each item scored from 0 to 4. The EAT-10 was designed specifically to address the clinical need for a rapidly self-administered and easily-scored questionnaire to assess the severity of dysphagia symptoms. An EAT-10 score ≥ 3 is abnormal and indicates the presence of swallowing difficulties. The EAT-10 has been confirmed to have excellent internal consistency, test-retest reproducibility, and criterion- based validity (27).

Table 1: 10-item Eating Assessment Tool. The subject is asked: “To what extent are the following scenarios problematic for you?”. Each item is scored from 0 (No problem) to 4 (Severe problem) according to the severity of the problem


In a previous study, we translated the EAT-10 into Japanese, and determined the reliability and validity of the Japanese version of the questionnaire (28). A cross-sectional study was performed in 393 frail, elderly subjects aged 65 years or older with dysphagia or suspected dysphagia. The severity of dysphagia was assessed using the Dysphagia Severity Scale, a 7-point ordinal scale consisting of 1, saliva aspiration; 2, food aspiration; 3, water aspiration; 4, occasional aspiration; 5, oral problems; 6, minimal problems; and 7, within normal limits (29). Points 1−6 indicate the presence of dysphagia, while points 1−4 represents dysphagia with aspiration. A total of 237 patients (60%) responded to the EAT-10. The Cronbach’s alpha coefficient was 0.946. The elderly subjects who could not respond to the EAT-10 were likely to have dysphagia. The sensitivity and specificity of not responding EAT-10 for dysphagia were 0.489 and 0.951, and for dysphagia with aspiration were 0.640 and 0.792, respectively. The median EAT-10 score of the 237 respondents was 1 (interquartile range: 0-9), with 101 respondents having a score ≥ 3. Our study showed there was a significant correlation between the EAT-10 score and the Dysphagia Severity Scale (r=-0.530, p<0.001). The sensitivity and specificity of the EAT-10 with a score ≥3 for dysphagia were 0.522 and 0.897, and for dysphagia with aspiration 0.758 and 0.749, respectively. EAT-10 is therefore a useful questionnaire to detect presbyphagia and dysphagia in frail elderly subjects.

Another screening method for dysphagia is bedside dysphagia tests, such as water or food swallowing tests, pulse oximetry, or cervical auscultation. A systematic review of bedside screening tests to detect dysphagia in patients with neurological disorders, showed the water test combined with pulse oximetry using coughing, choking, and voice alteration as endpoints was currently the best method (30). If the EAT-10 and bedside dysphagia screening tests are abnormal, further dysphagia assessment including observation of eating, videofluoroscopy, or videoendoscopic evaluation of swallowing is recommended. Although there are no characteristic swallowing changes in sarcopenic dysphagia, videofluoroscopy and videoendoscopic evaluation of swallowing can detect reduced laryngeal elevation, insufficient opening of the upper esophageal sphincter, pharyngeal residues in the valleculae and piriform sinus, and aspiration.


Sarcopenia assessment

Sarcopenia assessment should include muscle mass and strength and physical performance. Muscle mass is assessed using either computed tomography, magnetic resonance imaging, dual energy X-ray absorptiometry, bioimpedance analysis, ultrasonography, or anthropometry. Muscle strength is evaluated by handgrip strength or knee flexion/extension strength, while physical performance is assessed by the Short Physical Performance Battery, usual gait speed, or timed get- up-and-go test. Sarcopenia of swallowing muscles can be evaluated by measuring the muscle mass of the geniohyoid muscle or tongue thickness, and muscle strength of lingual pressure and head lift strength. However, further research is necessary to develop methods for measuring the mass and strength of the swallowing muscles.

Assessment of the multi-factorial causes of sarcopenia is also important, because sarcopenic dysphagia rehabilitation may differ depending on the causes of the disorder. Activity- related sarcopenia is suspected in elderly subjects with either hospital-associated deconditioning, the disuse syndrome (23, 24), history of no oral intake, bed rest, or a sedentary lifestyle for some period of time. Disease-related sarcopenia should be considered in elderly patients with a past or present history of advanced organ failure (heart, lung, liver, kidney, and brain), inflammatory disease, malignancy, or endocrine disease (21). Nutrition-related sarcopenia is suspected in elderly subjects with inadequate dietary intake of energy and/or protein which may occur with malabsorption, gastrointestinal disorders, or use of medications that cause anorexia (21). In fact, nutritional assessment is necessary when evaluating sarcopenic dysphagia, because a systematic review of nursing home patients showed difficulties swallowing or chewing and poor oral intake were associated with weight loss, low BMI, and malnutrition (31). Another systematic review of the relationship between dysphagia and malnutrition following stroke, reported the overall odds of being malnourished were higher in dysphagic subjects compared with subjects with intact swallowing (odds ratio, 2.425; 95% confidence interval, 1.264-4.649, p < 0.008)(32). These results indicate that elderly patients with dysphagia often have malnutrition as a complication. Causes of adult malnutrition are classified as being associated with either acute illness or injury, chronic illness, or social and environmental circumstances (33). The causes of adult malnutrition may also be involved in the etiology of nutrition- and disease-related sarcopenia, and may contribute to the development of sarcopenic dysphagia. Therefore, nutritional assessment is indispensable for evaluating sarcopenic dysphagia.


Consensus diagnostic criteria for sarcopenic dysphagia

A symposium of “sarcopenia and dysphagia rehabilitation” was held during the 19th Annual Meeting of the Japanese Society of Dysphagia Rehabilitation (symposium chair: Ichiro Fujishima and Hidetaka Wakabayashi). Consensus diagnostic criteria for sarcopenic dysphagia were proposed at the symposium (Table 2). Sarcopenic dysphagia is diagnosed only in patients with dysphagia and generalized sarcopenia (generalized loss of skeletal muscle mass and strength). Although some imaging test studies of swallowing muscles have been reported (25, 26), there is no cut-off point for judging loss of swallowing muscle mass. Therefore, evaluating the loss of swallowing muscle mass using imaging tests and a definitive diagnosis for sarcopenic dysphagia remains relatively difficult at present. Further research is necessary to determine the cut-off points for loss of swallowing muscle mass. However, if there are no other causes of dysphagia except sarcopenia in the patient’s clinical history, dysphagia is likely to be caused by sarcopenia, with sarcopenic dysphagia being considered as the most probable diagnosis. In cases in whom the existence of dysphagia may be caused by other conditions such as stroke, brain injury, neuromuscular diseases, head and neck cancer, and connective tissue diseases, it is possible to diagnose sarcopenic dysphagia if the main cause of dysphagia is considered to be sarcopenia.


Sarcopenic dysphagia rehabilitation

Therapy for sarcopenic dysphagia includes dysphagia rehabilitation and treatment of sarcopenia.


Dysphagia rehabilitation

The core components of dysphagia rehabilitation are oral health care, rehabilitative techniques, and food modification. In a systematic literature review of oral health care in frail older people, two studies showed that improvement of oral health care diminished the risk of developing aspiration pneumonia and also the risk of dying directly from aspiration pneumonia (34). Oral health care, consisting of tooth brushing after each meal, cleaning dentures once a day, and professional oral health care once a week, appeared to be the best intervention to reduce the incidence of aspiration pneumonia (34).

Table 2: Consensus diagnostic criteria for sarcopenic dysphagia

Rehabilitative technique, especially swallow muscle strength training, is an important component of dysphagia rehabilitation and presbyphagia treatment, although high quality evidence on its effectiveness is limited. A systematic review of the head lift exercise on the swallow function, reported positive effects including an increase in the anterior excursion of the larynx and anteroposterior diameter of the upper esophageal sphincter opening, associated with elimination of dysphagic symptoms (35). Lingual resistance exercise is another rehabilitative technique for patients with lingual weakness, swallowing disability due to frailty, other age-related conditions, or stroke (36, 37).

Compensatory procedures such as modification of food texture and liquid thickness are important strategies for dysphagia rehabilitation. Foods may be chopped, mashed, or puréed to compensate for chewing and swallowing difficulties, while liquids can be thickened to slow their transit through the oral and pharyngeal phases of swallowing to avoid aspiration. Because the number of levels of modification and characteristics vary within and across countries, the need for international standardized terminology and definitions for texture-modified foods and liquids for individuals with dysphagia have been emphasized (38). In Japan, texture- modified foods are now very advanced, and incorporate energy content (kcal), protein (g) and measures of hardness, adhesiveness, and cohesiveness for each food level (38). Instructions are also provided on whether the food should be served cold (15°C) or warm (45°C). Japanese clinicians also determine whether purée or jelly textures of extremely texture- modified foods are safer or easier to swallow (38).


Sarcopenia treatment

Treatment of sarcopenia should include resistance training combined with supplements containing amino acids, because these are considered to be the most effective option (39, 40). Treatment of activity-related sarcopenia is to avoid non-eating, bed rest, and a sedentary lifestyle, and to promote early oral intake, early mobilization, and physical activity. Treatment for disease-related sarcopenia requires therapies for advanced organ failure, inflammatory disease, malignancy or endocrine disease, while therapy for nutrition-related sarcopenia involves appropriate nutrition management to increase muscle mass. The causes of adult malnutrition may also contribute to the etiology of secondary sarcopenia and sarcopenic dysphagia. Therefore, nutrition management is indispensable for sarcopenic dysphagia rehabilitation. In cases of sarcopenia complicated by age-, activity-, nutrition-, and disease-related factors, treatment should include pharmaceutical therapies for age-related symptoms and comorbid chronic diseases, resistance training, early ambulation, nutrition management, protein and amino acid supplementation, and encouragement to stop smoking cigarettes (39, 40).



Presbyphagia and sarcopenic dysphagia are important current and future public health issues, because they are common in the elderly population and can lead to aspiration pneumonia, the prevalence of which is increasing in the aged society. Although there are no intervention studies for presbyphagia and sarcopenic dysphagia, therapies for sarcopenic dysphagia including dysphagia rehabilitation, sarcopenia treatment, and nutrition management appear to be important for treating these conditions. Developing diagnostic criteria for presbyphagia and sarcopenic dysphagia is necessary for epidemiological and intervention studies. Consensus diagnostic criteria for sarcopenic dysphagia were therefore proposed at the 19th Annual Meeting of the Japanese Society of Dysphagia Rehabilitation. Further research is also required on presbyphagia and sarcopenic dysphagia, especially evaluating swallowing muscle mass and strength in elderly subjects.

This manuscript was presented at the 20th International Association of Gerontology and Geriatrics World Congress of Gerontology and Geriatrics, Seoul, June 25, 2013, and the 19th Annual Meeting of the Japanese Society of Dysphagia Rehabilitation, Okayama, September 23, 2013.


Conflict of Interest: H. Wakabayashi has received reimbursement for travel expenses from Nestlé Health Sciences.

Acknowledgements: This study was supported by a Grant-in- Aid for the Comprehensive Research on Aging and Health from the Ministry of Health, Labor, and Welfare of Japan.


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