Impact of a lay-led home-based intervention programme on quality of life in community-dwelling pre-frail and frail older adults: a randomized controlled trial

Frailty is a serious emergent health-related problem in older adults [1]. Several studies have shown that functional disabilities and limitations on independency, caused by the frailty syndrome are associated with poor quality of life (QoL) [2‐4], while others studies have shown that low QoL among older adults is linked with various negative health outcomes, including falls and nursing home placement [5]. In this context, numerous studies reflect that a broad majority of older people want to remain in their own homes as long as possible. Nevertheless, aging in place can become difficult if functional ability and the related meaningful activities (e.g. take care of the household, running daily errands) are no longer possible to be independently performed [6, 7]. Independence and functional ability thus plays an important role for maintaining physical and psychological health in frail older adults [5].

However, it is not only the objective changes in health and social structures that are important for the living situation in old age, but also the number of social contacts as well as the quality of social relations, which are associated with morbidity and mortality [8]. The higher the age, the smaller will the social network be. Especially under conditions of frailty, this has unfavourable effects on the QoL [9]. Consequently, older adults’ QoL can be improved and maintained at a high level, even with poor physical health, as long as they are satisfied with other dimensions of QoL, such as mental health, social and environmental relationships, and socioeconomic status [10]. Hence, a broad-ranging evaluation of QoL has become an essential component of many clinical studies across a wide range of patient populations [11].

The main objective of exercises for older adults is to increase their physical capacity to perform daily activities, such as getting out of a chair or climbing stairs and with it maintaining functional independence and QoL [12, 13]. The loss of strength and impaired static and dynamic postural control lead to increased frequency of falls, often with serious consequences with the loss of autonomy and decreased QoL [14]. The effects which can be achieved through resistance training, demonstrate the need for muscle training in old age [15]. Apart from the degree of frailty, the format and intensity of the exercise intervention, evidence indicates that physical activity and a balanced, healthy diet can improve and maintain the QoL in older adults [16‐19].

Due to the demographic development, were there is a growing percentage of homebound frail old people [20] and apart from the basic need for at home care, the provision of exercise intervention and social support for frail older people has become a key concern of Austria’s social policy. Additionally, according to the Austrian Volunteer Report [21] the largest area of formal voluntary work is in the field of sports and exercise. There is already good evidence that volunteering can yield double benefits, for the recipient and the volunteer themselves, in terms of improved self-esteem, well-being and social engagement [22‐24]. Our research team recently demonstrated that a lay-led home-based physical activity and nutritional intervention programme can increase handgrip strength, physical performance, nutritional and frailty status [25, 26]. To further explore whether such an approach can influence QoL, we compared the effects of a lay-led home-based physical and nutritional intervention programme with social support alone on various QoL dimensions in community-dwelling pre-frail and frail older adults. In addition we also wanted to know which factors were associated with improvements in several QoL domains.

The combined nutrition and exercise intervention did not lead to significant improvements in QoL compared to social support only. However, even though we only found significant group differences in the past, present and future activities, it is important to note that we saw some evidence of greater within group improvements in the PTN group, particularly in overall QoL, social relations and social participation. The positive effects with regard in the past, present and future activities domain, it can be assumed that the activities undertaken in the home visits (e.g., conversations about nutrition, exercise and social support), as a result of the intervention programme, was perceived as positive, and that this current status should be upheld in order to live independently at home as long as possible. In this context, the study of Salkeld et al. [44] showed that, after a hip fracture, 80% of older women stated that they preferred death to losing their independence or to possible admission to a nursing home.

Although the physical performance and physical activity in our study shows a significant improvement, there were no significant changes in the physical health domain. It can be expected that an active lifestyle preserves physical function in older adults [45], which in turn leads to higher levels of QOL scores in domains related to physical health [46]. The present study was not able to demonstrate greater values in the physical health domain. One possible explanation for the unchanged values is that almost 68% of the participants had at baseline a low performance score (less than 6 points), 24% had a moderate score and 8% had a high score (more than 10 points) in the SPPB. Thus, a total score lower than 6 points is considered an indication of serious functional limitations in older adults [47]. These results imply that the physical health (e.g. pain, discomfort, sufficient sleep, rest and good work capacity) due to serious functional limitations in this population may be responsible for the lack of change. However, as evident in our study the SPPB score improved of at least 1 point. An improvement of one to two points is already substantial [48‐50]. Thus, this trial is likely to be worthwhile considering the importance of physical activity in homebound older people.

A further explanation for unchanged value can be partly explained by the fact that home visits with social support alone had a tendency towards improvement and due to the limited statistical power. A study in South Korea indicated that social support influences QoL in older adults in a positive way [51]. Moreover, a two-year longitudinal study showed that social frailty (i.e., living alone, lack of social contacts and lack of social support) was associated with receiving nursing care and the number of contacts with health care professionals [52]. It is not surprising that in the qualitative study of Puts et al. [53], social contact was identified as the most important factor for pre-frail or frail people. In addition, the results of Seeman [54] demonstrated an association between increased levels of social support and reduced risk of physical disease, mental illness and mortality, while, in contrast, older participants who were lacking in social relationships and contacts were found to have a higher possibility of suffering from loneliness during their daily activities [55]. Hence, it is possible that a supportive atmosphere with social exchange, as experienced by the SOSU group, might be positively linked to the minor changes in the QoL domains. However, surprisingly, the SOSU group showed no significant change in any QoL domain. One possible explanation for this could be that the highly motivated participants recruited through the media, who were allocated to the SOSU group, were dissatisfied with the lack of activities or, as can be seen in Fig. 1, were disappointed not to be in the PTN group.

The adherence rate of 75% in our study, which is comparable to similar studies analysed in the meta-analysis of Chou et al. [56], was essential to the success of our intervention, and likely resulted from the social interaction and the encouragement of the volunteers. In addition, the home-based exercises were not connected to any adverse events (apart from one person with back pain), and appear to be safe. In summary, this highlights the importance of the measures being tailored to the resources of the pre-frail and frail older adults, in order to achieve a high level of adherence and, thereby, an effect.

There is large body of evidence supports the claim that physical exercise has a positive impact on heath related QoL, even if it is not performed simultaneously to a nutritional intervention [57, 58]. As presented in Table 3, changes in nutritional status were found to be related to changes in social participation. In this respect, the study of Kwon et al., [59] who demonstrated that an exercise programme alone did not result in a significant change in health-related QoL when compared to a combined exercise and nutritional intervention programme. However, interestingly we found a negative association between change in nutritional status and change in the past, present and future activities domain when adjusted for sex and age, which is difficult to interpret.

Finally, in the context of the linkage between older lay volunteers and pre-frail or frail older adults, Puts et al. [53] stated that, for non-frail people, health plays a central role for a good QoL, and that the importance of helping others, as well as social activity, is also beneficial for a good QoL. Considering that many health professionals have limited time resources [60] to deliver exercise interventions during a routine home visit, social interchange is understandably not always possible. Thus, this kind of association can yield double benefits. On the one hand, the health status of both the pre-frail and frail subjects and the older lay volunteers can improve, due to the active engagement with nutritious food and physical training and, in particular, through the health education. However, the improvement in the health status of the volunteers still needs to be examined. While using senior volunteers in health promotion has many benefits [61] (e.g. cost effective, feeling useful and self-fulfilled, be part of a community, reduced symptoms of depression) there are also some disadvantages. For instance, the burden on volunteers in respect to training and service delivery can be overwhelming, and due to disability and illness, which are more prevalent in older age groups, the dropout rate can be high [62]. However, the pairing between lay volunteers and frail older adults can work well, provided that lay volunteers are well trained to ensure that they do not operate outside their sphere of competence.

The mayor strength of this study is the implementation of the lay-led home-based programme, which adds new information to the knowledge about the effectiveness of nutritional education, social support and physical training delivered by lay volunteers. Such “buddy system” could be used as a resource in terms of reaching frail older adults who are bound to their own homes.

The linking of lay volunteers with frail older adults in a structured programme with physical training and nutritional intervention was not effective compared to social support on several QoL domains in community-dwelling pre-frail and frail older adults. However, the small but significant improvement within the PTN group suggests that a home-based physical and nutritional intervention delivered by volunteers may influence the QoL in a positive way.