Effects of health care interventions on quality of life among frail elderly: a systematized review

Figures & data

Figure 1 Study selection flowchart.

Abbreviation: ADL, activities of daily life.

Figure 2 Methodological quality of the included studies, using the Cochrane collaboration’s tool for assessing risk of bias.

Figure 3 Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies.

Table 1 An overview of the included studies, characteristics and outcomes

Reference	Study population	Design	Definition of frailty	Intervention	Control group	Results
Cameron et al, 2013^Citation27	Frail adults aged ≥70 years who completed their treatment within the division of Rehabilitation and Aged Care Services in Australia, not living in a residential aged care facility (n=241)	Randomized controlled trial	CHS criteria for frailty (≥3 of the following: weak grip, slow gait, exhaustion, low energy expenditure, and weight loss)	Interdisciplinary treatment program targeting the identified characteristics of frailty for a 12-month period	Usual care	3 months: EQ-5D VAS: Mean ± SD deviation Intervention (n=108): 60.6±20.1 Control (n=117): 60.3±16.9, P=0.99 12 months (after treatment): EQ-5D VAS: Mean ± SD deviation Intervention (n=107): 57.5±20.8 Control (n=108): 57.7±19.7, P=0.91
Chan et al, 2017^Citation28	Frail elderly, aged ≥65 years, openly recruited from neighborhood elderly centers in Hong Kong (n=101)	Multicenter, randomized controlled trial	Tilburg Frailty Indicator ≥5	12-week acupressure intervention four times a week during 15 minutes. Given twice by a caregiver dyad and twice by a registered Chinese medicine practitioner	Waiting list	End of treatment (after 12 weeks): Intervention group (n=50), control group (n=51) measurement: Mean int. group, mean control group, P-value WHOQOL-BREF Overall QoL: 3.70, 3.45, P=0.105 General health: 3.23, 3.10, P=0.140 Physical domain: 63.49, 56.52, P=0.001 Psychological domain: 67.91, 64.89, P=0.043 Social domain: 64.45, 63.70, P=0.013 Environment domain: 71.61, 68.13, P=0.006
Cohen et al, 2002^Citation29	Frail patients, aged ≥65 years and hospitalized at a Veterans Affairs medical center in the USA (n=409 included in trial)	Randomized controlled trial	Patients who met ≥ two of the following criteria were considered to be frail: inability to perform one or more ADL, a stroke ≤ three months, history of falls, difficulty walking, malnutrition, dementia, depression, ≥ one unplanned admissions in the previous three months, prolonged bed rest, or incontinence	Care in an inpatient geriatric unit followed by care at an outpatient geriatric clinic. The interventions involved teams that provided geriatric assessment and management	Usual inpatient care followed by usual outpatient care	Inpatient geriatric care At discharge: Positive effect on following domains of SF-36: MeanΔint. group, meanΔcontrol groupa, P-value • physical functioning: −1.5, −5.4, P=0.006 • bodily pain: 15.3, 9.2, P=0.001 • energy: 0.8, −2.6, P=0.01 • general health: −0.02, −3.4, P=0.006 At one year: Positive effect on following domains of SF-36: MeanΔint. group, meanΔcontrol groupa, P-value • Bodily pain: 24.9, 20.0, P=0.01 Outpatient geriatric careAt one year: Positive effect on following domains of SF-36: MeanΔint. group, meanΔcontrol groupa, P-value • energy: 0.8, −2.5, P=0.009 • mental health: −0.6, −1.2, P=0.001 • general health: −0.5, −2.9, P=0.01 At one year: Positive effect on following domain of SF-36: MeanΔint. group, meanΔcontrol groupb, P-value • mental health: 5.7, 1.5, P=0.004 Ninety-nine percent of all planned follow-up interviews were conducted successfully by telephone according to the author
Ekerstad et al, 2017^Citation40	Frail elderly, aged ≥75 year, in need of acute in-hospital treatment in Sweden (n=408)	Randomized controlled, one center, trial	Two or more criteria from the Frail Elderly Support research group screening instrument	Structured, systematic interdisciplinary comprehensive geriatric assessment-based care at an acute elderly care unit	Usual care	3 months after discharge: Intervention group (n=179), control group (n=166) measurement: Mean int. group, mean control group, P-value HUI-3-vision: 0.873, 0.862, P=0.664 HUI-3-Hearing: 0.818, 0.817, P=0.976 HUI-3-Speech: 0.995, 0.985, P=0.036 HUI-3-Ambulation: 0.584, 0.458, P=0.001 HUI-3-Dexterity: 0.856, 0.804, P=0.122 HUI-3-Emotion: 0.896, 0.896, P=0.963 HUI-3-Cognition: 0.933, 0.834, P<0.001 HUI-3-Pain: 0.766, 0.594, P<0.001
Fairhall et al, 2015^Citation30	Frail community-dwelling people who were discharged from a rehabilitation division of a Health Service in Sydney, aged ≥70 years (n=241)	Cost-effectiveness study embedded in a randomized controlled trial	CHS criteria for frailty (≥3 of the following: weak grip, slow gait, exhaustion, low energy expenditure, and weight loss)	12-month interdisciplinary, multifactorial intervention targeting the components of frailty, delivered by an interdisciplinary team	Usual care	3 months (n=): EQ-5D: Mean ± SD deviation Intervention: 0.56±0.31 Control: 0.47±0.34 P=0.24 12 months (after treatment) (n=216): EQ-5D: Mean ± SD deviation Intervention: 0.49±0.32 Control: 0.47±0.34P=0.74 216 of the 241 randomized participants completed the study
Favela et al, 2013^Citation31	Frail adults aged >60 years, living in Mexico with health insurance supplied by the Mexican Social Security Institute (n=133)	Randomized controlled trial	Frailty index score ≥0.14. Count of different symptoms, illnesses, and other conditions (n=34). Frailty index score = number of items present/number of total items	Weekly nurse home visits over a 9-month period including alert buttons vs nurse home visits alone	Usual care	This information was requested from the authors No statistically significant difference between groups on the different domains of the SF-36 Intervention nurse home visits including alert buttons: n=39 Intervention nurse home visits: n=37 control: n=39
Giné-Garriga et al, 2013^Citation32	Frail adults, 80–90 years old, selected from a primary health care center in the Barcelona area (n=51)	Randomized controlled trial	Frail when (a) more than 10 seconds to perform a rapid-gait test; (b) could not stand up five times; or (c) if found frail by the (Fried) exhaustion criterion	12-week functional circuit training program: combination of functional balance and lower body strength-based exercises twice a week	Usual care with health education meetings once a week	12 weeks: Mean ± SD deviation SF-12 PCS/SF-12 MCS Intervention (n=22): 35.59±4.41/38.37±7.14 Control (n=19): 29.80±3.74/31.14±8.56 P<0.001/P=0.001 36 weeks: Mean ± SD deviation SF-12 PCS/SF-12 MCS Intervention (n=18): 36.52±4.47/33.94±6.18 Control (n=7): 29.26±3.05/30.53±7.41 P<0.001
Hempenius et al, 2013^Citation22 Hempenius et al, 2016^Citation21	Frail patients, aged >65 years	Randomized controlled trial	GFI score >3. The GFI screens for loss of function and resources in four domains: physical, cognitive, social and psychological	Preoperative geriatric consultation, an individual treatment plan targeting risk factors for delirium, daily visits by a geriatric nurse during the hospital stay and advice on managing any problems encountered	Usual care	Univariate binary logistic regression analysis, outcome score of the SF-36 were dichotomized as same/better or worse scores Intervention (n=127) Control (n=133) At discharge: Positive effect on following domains of SF-36: • bodily pain (OR: 0.49, 95% CI: 0.29–0.82) 3 months after discharge: SF-36-MCS: OR 0.84 (95% CI: 0.50–1.42) Intervention (n=106) Control (n=121)
Hoogeboom et al, 2010^Citation33	Frail elderly aged ≥70 years with hip osteoarthritis awaiting total hip replacement in the Netherlands (n= 21)	Pilot randomized controlled trial	Score of ≥2 on the CSHA Clinical Frailty Scale; the Clinical Frailty Scale ranges from 1 (robust health) to 7 (complete functional dependence on others)	A short (3–6 weeks) preoperative tailor-made, therapeutic exercise program at least twice a week. Patients were encouraged to exercise at home	Usual care	Preoperative: HOOS QoL: Mean ± SD deviation Intervention (n=10): 36.3±15.8 Control (n=10): 43.3±15.4 Adj mean diff. (95% CI): -1.2 (13.0–10.7) No statistically significant differences between groups
Hoogendijk et al 2016^Citation34	Community-dwelling frail older adults aged ≥65 years recruited through 35 primary care practices in the Netherlands (n=1,147)	Stepped wedge cluster randomized controlled trial	PRISMA-7 score of ≥3 PRISMA-7 is a brief 7-item questionnaire containing risk factors for functional decline	Geriatric Care Model (GCM): a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Complex patients were reviewed in multidisciplinary consultations	Usual care	6 months: Measurement: B (95% CI), P-value SF-12 MCS: −0.22 (-0.91–0.46), P=0.52 SF-12 PCS: 0.25 (−0.53–1.03), P=0.53 EQ5D: 0.01 (−0.01–0.03), P=0.37 12 months: Measurement: B (95% CI) SF-12 MCS: 0.34 (−0.55–1.22), P=0.46 SF-12 PCS: 0. −0.37 (−1.38–0.64), P=0.47 EQ5D: 0.01 (−0.01 −0.04), P=0.24 18 months: SF-12 MCS: 0.06 (−1.08–1.20), P=0.92 SF-12 PCS: 0.01 (−1.29–1.30), P=0.99 EQ5D: 0.03 (0.00–0.06), P=0.06 24 months: SF-12 MCS: -0.80 (-−2.31–0.72), P=0.30 SF-12 PCS: −0.11 (−1.83–1.61), P=0.90 EQ5D: 0.01 (−0.03–0.05), P=0.63 782 (68.2%) frail older adults completed the full 24-month study period
Kircher et al, 2007^Citation38	Frail patients who were hospitalized in hospitals with a geriatric evaluation and management (GEM) team in Germany, at least 65 years old (n=345). Patients from hospitals without this team formed an external comparison group (n=90)	Randomized controlled trial	≥2 of the criteria proposed by Lachs et al (measuring vision, hearing, arm and leg function, urinary incontinence, nutrition, mental status, depression, instrumental and basic activities of daily living, environmental hazards, and social support systems)	Comprehensive geriatric assessment and management in the form of consultations and follow-up provided by the GEM team	Control group: Usual care Comparison group: usual care in other hospitals (without GEM team present)	3 months follow up: QoL Philadelphia Geriatric Center Morale Scale: Mean (SD) GEM group (n=122): 7 (6–10) Control group (n=107): 8 (6–9) Comparison group (n=60): 9 (7–9) 12 months follow up: QoL Philadelphia Geriatric Center Morale Scale: Mean (SD) GEM group (n=83): 8 (7–9) Control group (n=78): 8 (7–10) Comparison group (n=29): 8 (6–9) No statistically significant differences between groups
Langlois et al, 2013^Citation39	Frail older adults, aged 61–89 years (n=83; 34 frail older adults and 38 non-frail older adults)	Matched-control group design	Participants were categorized as frail if they met at least two of the three following diagnostic criteria: (a) three of the five symptoms defined by Fried et al, (b) a score of ≤28/36 on the modified Physical Performance Test, (c) identified as frail according to the geriatrician’s judgment based on the frailty index. To be classified as non-frail, participants could not meet any of these three frailty criteria	Physical exercise-training program consisted of 12 weeks of 1-hour exercise session 3 days a week	Participants were instructed to maintain their current level of activity. After participating in the study, they were offered the opportunity to join a physical training program	After 12 weeks: QoL Systemic Inventory questionnaire Global QoL: Main group effect: F(1, 68)=3.97, P=0.05 Z score change frail elderly: 0.09 Leisure activities Main group effect: F(1, 68)=9.13, P=0.004 Z score change frail elderly: 0.35 Perception of physical capacity Main group effect: F(1, 68)=5.76, P=0.019 Z score change frail elderly: 0.44 Social/family relationships Main group effect: F(1, 68)=4.41, P=0.039 Z score change frail elderly: 0.14 Perceived physical health Main group effect: F(1, 68)=4.40, P=0.040 Z score change frail elderly: 0.27 No group × frailty interactions were reported. Significant differences between groups on these domains. Intervention (n=36) Control (n=36)
Latham et al, 2003^Citation35	Frail patients aged 65 and older admitted to geriatric rehabilitation units in New Zealand and Australia (n=243)	Randomized controlled trial	Frail patients were those who had one or more health problems or functional limitations from a list of indicators that included dependency in an activity of daily living (ADL), prolonged bed rest, impaired mobility, or a recent fall	Single dose of vitamin D 10 weeks of high-intensity quadriceps resistance exercise three times a week started in the hospital and continued at home	Placebo tablet Social home visits (attention)	3-month follow-up: PCS SF-36: Mean (95% CI): Resistance exercise (n=112): 34 (32–36) Attention control (n=110): 35 (33–37) Vitamin D (n=108): 35 (33–37) Placebo (n=114): 35 ± (33–36) No statistically significant differences between groups
Looman et al, 2014^Citation24 Looman et al, 2016^Citation23	All GP patients aged ≥75 years of the 3 GP practices in the experimental (n=222) and 6 GP practices in the control group (n=224)	Quasi-experimental study	GFI score ≥4	Preventive integrated care model: Comprehensive assessment of care needs with EASYcare. Treatment goals were translated into a multidisciplinary treatment plan	Usual care	3 months follow-up: Intervention group (n=205), control group (n=212) measurement, mean int. group, mean control group, P-value General QoL (based on RAND-36): 40.56, 40.95, P=0.14 EQ-6D-mobility: 1.73, 1.71, P=0.44 EQ-6D-self-care: 1.48, 1.39, P=0.30 EQ-6D-daily activities: 1.73, 1.71, P=0.29 EQ-6D-pain/discomfort: 1.81, 1.79, P=0.78 EQ-6D-anxiety/depression: 1.46, 1.46, P=0.38 EQ-6D-cognitive functioning: 1.49, 1.51, P=0.75 ICECAP-role: 2.56, 2.68, P=0.69 ICECAP-enjoyment: 2.81, 2.68, P=0.61 ICECAP-security: 3.25, 3.18, P=0.12 ICECAP-control: 2.53, 2.68, P=0.83 ICECAP-attachment: 3.08, 2.86, P=0.03 12 months follow-up: Intervention group (n=222), control group (n=224) measurement: mean int. group, mean control group, P-value General QoL (based on RAND-36): 42.66, 39.92, P=0.06 EQ-5D: 0.66, 0.65, P=0.73 ICECAP-attachment: 3.00, 2.75, P<0.001 ICECAP-security: 3.32, 3.28, P=0.45 ICECAP-role: 2.57, 2.54, P=0.66 ICECAP-enjoyment: 2.73, 2.66, P=0.30 ICECAP-control: 2.55, 2.61, P=0.27
Metzelthin et al, 2014^Citation25 Metzelthin et al, 2015^Citation26	Community-dwelling frail older people, aged ≥70 years in the south of the Netherlands, recruited from GP practices (n=346)	Cluster randomized controlled trial	GFI score ≥5 points	Proactive primary care approach which included an in-home assessment and interdisciplinary care based on a tailor-made treatment plan	Usual care	6-month follow-up: EQ-5D based on NL tariff: mean ± SD Intervention group (n=171): 0.68±0.19 Control group (n=145): 0.73±0.17 P=0.34 12-month follow-up: Intervention group (n=157): 0.69±0.18 Control group (n=141): 0.72±0.16 P=0.81 24-month follow-up: Intervention group (n=143): 0.68±0.17 Control group (n=127): 0.69±0.19 P=0.97 Also data available based on UK tariff:no statistically significant differences between groups no significant group by time interaction effects of the intervention group on QoL
O’Connell et al, 2011^Citation19 Srinivas-Shankar et al, 2010^Citation20	Intermediate frail or frail community-dwelling men aged ≥65 years with low testosterone levels, recruited by advertisements or mailed invitations from family practice registers in England (n=274)	Randomized controlled trial	Based on the criteria of Fried: unintentional weight loss, self-reported exhaustion, low physical activity, slow walk time and low handgrip strength. Intermediate frail: 1 or 2 criteria, frail: 3 or more criteria of Fried	6 months testosterone gel (25 or 75 mg daily)	Placebo	6 months (after treatment): AMS somatic subscale: mean ± SD deviation Intervention (n=130): 12.7±4.3 Control (n=132): 13.8±4.7 P=0.04 AMS psychological subscale: mean ± SD deviation Intervention (n=130): 8.2±3.5 Control (n=132): 7.6±3.2 P=0.83 12 months: AMS somatic subscale: Mean ± SD deviation Intervention (n=104): 14.1±4.4 Control (n=104): 15.1±5.4 P=0.08 AMS psychological subscale: mean ± SD deviation Intervention (n=104): 7.6±3.6 Control (n=104): 8.2±3.9 P=0.091
Oosting et al, 2012^Citation36	Frail patients, aged >65 years, scheduled for elective total hip arthroplasty in the Netherlands (n= 30)	Pilot randomized controlled trial	Score of 2 or higher on the frailty index ISAR which consists of six self-report questions on functional dependence, recent hospitalization impaired memory and vision and polymedication.	A preoperative program to train functional activities and walking capacity twice a week for 3–6 weeks during supervised sessions and instructions to additionally train 4 times/week at home and use a pedometer	Usual care which consisted of a single group information session	Before admission (t1): HOOS: Mean ± SD deviation Intervention (n=15): 77.0±10.1 Control (n=13): 80.4±11.1 6 weeks after discharge (t3): HOOS: Mean ± SD deviation Intervention (n=14): 53.2±16.4 Control (n=12): 49.2±16.1 No statistically significant differences between groups
Van Hout et al, 2010^Citation37	Frail elderly, age ≥75 years and listed as primary care patient, living at home in the Netherlands (n=651)	Randomized controlled trial	Frail: self-reported score in the worst quartile of at least two of six COOP-WONCA charts	Preventive home visiting program, with seven key characteristics including assessment of health risks and care needs an individually tailored care plans and nurse home visits	Usual care	SF-36 physical component: mean ± SD deviation 6-month follow-up: Intervention (n=244): 31.4±9.3 Usual care (n=229): 32.1±9.4 18-month follow-up: Intervention (n=215): 30.7±9.2 Usual care (n=209): 32.2±9.3 SF-36 mental component: mean ± SD deviation 6-month follow-up: Intervention (n=244): 44.5±10.5 Usual care (n=229): 45.4±10.6 18-month follow-up: Intervention (n=215): 43.9±11.2 Usual care (n=209): 45.2±11.2 No statistically significant differences between groups
Yuri et al, 2016^Citation41	Frail older people aged ≥65 years, living in the community in Izumi, Osaka, Japan (n=143)	A cluster nonrandomized controlled trial	The 25-item Kihon Checklist has seven domains: activities of daily living, physical strength, nutritional status, oral function, houseboundness, cognitive function and depression risk. According to Japanese frailty criteria, eligibility for this study was defined as having one or more of the following: “low physical strength,” “low nutritional status,” “low oral function,” or “generally frail” status	Standard preventive care program in combination with life goal-setting support (SPCP + LGST)	Standard preventive care program (SPCP): physical exercise classes, oral care and nutrition education	QoL: 5 point Likert scale. group: mean (SD) Baseline: Intervention: 3.14±0.78 Control: 3.23±0.84 3 months Intervention (n=65): 3.81±0.80; P=0.001* Control (n=61): 3.30±0.81; P=0.970 6 months Intervention (n=53): 3.50±0.74; P=0.078 Control (n=52): 3.23±0.91; P=1.000 9 months Intervention (n=42): 3.36±0.66; P=0.415 Control (n=47): 3.23±0.91; P=1.000 Time × group interaction effect P=0.022

Notes:

a MeanΔint.group, meanΔcontrol group: mean change in score between baseline and discharge/12 months. Mean change in score given for the intervention group and the control group.

b MeanΔint.group, meanΔcontrol group: mean change in score between discharge and 12 months.

Abbreviations: ADL, activity of daily living; CHS, Cardiovascular Health Study; CSHA, ; COOP-WONCA, ; GEM, geriatric evaluation and management; GFI, Groningen Frailty Indicator; GP, general practitioner; HOOS QoL, Hip disability and Osteoarthritis Outcome Score - quality of life subscale; HUI-3, Health Utilities Index-3; ICECAP, Investigating Choice Experiments for CAPability measure for Older people; ISAR, Identification of Seniors At Risk; Mean int. group, mean score of intervention group (at the described follow-up period); QoL, quality of life; SF-12 MCS, Short form-12 mental health composite scale; SF-12 PCS, Short form-12 physical health composite scale; SF-36 MCS, Short form-36 mental health composite scale; WHOQOL-BREF, WHO Quality of Life-BREF.

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