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Nutritional intervention and physical training in malnourished frail community-dwelling elderly persons carried out by trained lay “buddies”: study protocol of a randomized controlled trial
BMC Public Health volume 13, Article number: 1232 (2013)
In elderly persons frailty and malnutrition are very common and can lead to serious health hazards such as increased mortality, morbidity, dependency, institutionalization and a reduced quality of life. In Austria, the prevalence of frailty and malnutrition are increasing steadily and are becoming a challenge for our social system. Physical training and adequate nutrition may improve this situation.
In this randomized controlled trial, 80 malnourished frail community-dwelling patients (≥ 65 years) hospitalized at wards for internal medicine are recruited. Additionally, 80 lay volunteers (≥ 50 years), named buddies are recruited and subsequently trained regarding health enhancing physical activity and nutrition in four standardized training sessions. These buddies visit the malnourished frail persons at home twice a week for about one hour during an initial period of 10–12 weeks. While participants allocated to the intervention group (n = 40) receive intervention to improve their fluid intake, protein and energy intake, perform strength training and try to increase their baseline activities, the control group (n = 40) only gets home visits without any intervention. After 10–12 weeks, both, the intervention and the control group, receive the nutritional intervention and the physical training. Health, nutritional and frailty status, physical fitness, body composition and chronic inflammation of buddies and frail persons are recorded before the intervention, after 10–12 weeks, 6 and 12 months.
To your knowledge this trial is the first of its kind to provide nutritional and physical activity interventions to malnourished frail community-dwelling persons by trained lay buddies, in which an improvement of the frail persons´ and the buddies’ health status is measured. This study assesses the efficacy of such an intervention and may offer new perspectives for the management of frailty and malnutrition.
Frailty is considered as a state of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for long-term care and mortality . Moreover, other difficulties regarding frailty include morbidity, hospitalization, social isolation and an overall decrease in quality of life . According to the Frailty Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI) , the prevalence of frailty in persons older than 65 years is 17%. Additionally, 42.3% are pre-frail, which is an intermediate state between being robust and frail. In Austria, the prevalence of frailty is 10.8%, pre-frailty appears in 40.7% of community-dwelling older people . Through extrapolation of the predicted demographic development, a number of 356,000 frail and 1.5 million pre-frail persons may be expected in 2050 in Austria . Due to this epidemiologic trend, treatment and especially prevention of frailty is becoming one of the greatest challenges for our social system.
Sarcopenia, which is defined as reduced muscle mass and strength and impaired muscle performance , significantly contribute to the development of frailty . Underlying reasons for sarcopenia are the ageing process, heritability, an unbalanced diet, a sedentary lifestyle and chronic diseases [8–10]. Within the existing literature, the prevalence of sarcopenia in 60 to 70-year old people is between 5–13%  and in the population aged 80 years or older it increases to 11–50% .
In addition, malnutrition is associated with a higher risk of becoming frail and it contributes to its pathogenesis [7, 12–14]. It is defined as a chronic state in which a combination of over- and undernutrition and inflammatory activity modifies the body composition [15, 16] and consequently may lead to serious health hazards [17–22]. According to a review by Guigoz et al. the prevalence of malnutrition in hospitalized patients is 23% and 46% are at risk of malnutrition, respectively .
Furthermore, chronic inflammation parameters e.g. leukocytes, interleukin 6 (IL-6), tumour necrosis factor (TNF-alpha) [24, 25] and c-reactive-protein (CRP) [24–26] are associated with both, malnutrition and frailty. Moreover, deficits in vitamin D, with its benefit on bone, muscle, and nerve function , could be a sign of malnutrition [28, 29]. In addition, low levels of serum proteins e.g. albumin and transferrin, and of total cholesterol and triglycerides might indicate malnutrition .
As nutritional and frailty status frequently deteriorate post-discharge , it can be concluded that energy and especially protein intake must be improved in frail malnourished elderly persons who are still living at home. An individualized nutritional counseling, which takes place three times at patients’ home after discharge, and is conducted by registered dietitian has the potential to improve the nutritional status within 12 weeks . Moreover, exercise training, especially strength training, can improve health status and quality of life [33, 34]. According to the fact that a lack of strength is one of the major cause of falls and consequences in frail persons [35–37], strength training may empower elderly people to maintain or regain autonomy and independency. Therefore, a home-based well-structured nutritional intervention program in combination with strength training can be considered as an effective therapeutic option for the treatment of frailty  and malnutrition. Due to this intervention the negative outcomes of frailty and malnutrition are expected to be reduced and should help older persons to maintain or even improve their quality of life. Additionally, the general well-being, muscle strength, and activities of daily living are expected to improve .
The proposed study is designed as a prospective randomized controlled trial taking place in Vienna, Austria. A randomization design, which is stratified by handgrip strength, is chosen to get two comparable groups of participants in the intervention and the control group. In the study 80 community-dwelling malnourished frail persons are recruited. They are visited by buddies (volunteers ≥ 50 years) twice a week for about one hour for 6 months. An overview of the study design and the assessment points is provided in Figure 1.
The study was approved by the local ethical committee of the Medical University Vienna (Ref: 1416/2013) and complies with the Declaration of Helsinki . Furthermore, the protocol was registered at clinicaltrials.gov (Identifier: NCT01991639). The study methods are in accordance with the CONSORT guidelines for reporting randomized trials .
The methods presented in this study are built upon two pre-studies. The findings of the first pre-study illustrated that 54.13% of people over the age of 65 years (n = 133) inpatient in the ward for internal medicine in acute hospitals in Vienna are frail and 25.56% are malnourished. Additionally, even more are at higher risk (pre-frail: 21.8%; at risk of malnutrition: 51.13%) [39, 42]. Moreover, this pre-study showed that 64.7% of the participants are willing to improve their health situation and they are interested in a home-based program (64.7%), which is based on strength training and improvement of nutritional habits.
The second pre-study by Müller et al. proved that with the help of the Austrian charitable organizations it is possible to recruit a sufficient number of volunteers, who are willing to perform and supervise the exercise program and the nutritional intervention. Furthermore, in this pre-study the buddies were trained and educated in a one-day workshop. After one month their knowledge and skills concerning the most important aspects of healthy nutrition and exercise training were tested. The results of this pilot study showed that with an extensive preparation lay people, older than 50 years, are certainly capable to conduct these interventions . However, a several-day workshop should be preferred to train the buddies.
The primary objective of the study is to increase the handgrip strength by this intervention, measured with a dynamometer. Further aims of the proposed study are to improve the nutritional status, to increase the amount of health enhancing physical activity and to improve the overall health status in malnourished frail community-dwelling older people and buddies.
Due to the project design, the social networks and social interaction of buddies and frail person is expected to be strengthened. In addition, health resources and quality of life should be increased.
A clear objective of this study is to perform the nutritional and physical training intervention in malnourished frail people’s home environment.
Recruitment and eligibility
Malnourished frail persons
Malnourished frail people 65 years and older, who are inpatient in five hospitals in Vienna, wards for internal medicine, and close to discharge are recruited in four waves within one year. The inclusion and exclusion criteria for malnourished frail persons are shown in Table 1.
The buddies are recruited in cooperation with the “Wiener Hilfswerk” in four waves within one year. The “Wiener Hilfswerk” is one of the largest organizations in Austria, which already offers care-giving services for elderly persons carried out by volunteers. The inclusion criteria for buddies are:
50 years or older
Readiness to participate in the study either in the intervention or control group
Commitment to keep to the protocol for at least 6 months
Sample size calculation
For sample size calculation, the difference in handgrip strength from the first assessment point (AP1) to the second assessment point (AP2), which take place 10–12 weeks after AP1 (see Figure 1), is considered as a marker of muscle strength. We examine its relationship with diet [24, 33] and physical activity  in a community-dwelling cohort. Given a clinically relevant difference of 2 kg in handgrip strength (intervention group improves by 2 kg more than the control group in handgrip strength), a standard deviation of 3 kg of the differences, a two-sided significance level of 0.05, a sample size of n = 36 per group is needed to reach 80% statistical power. Since imputation for drop-outs may have some inestimable effect on the assumed standard deviation of the differences, the sample size is increased to n = 40 per group. Expected value μ1 (intervention) = 16 kg, μ2 (control) = 14 kg (based on the results of the pre-study [42, 44]). The primary endpoint is analyzed according to the intention-to-treat principle (ITT).
Persons are randomly assigned to the intervention or control group, stratified by handgrip strength with the help of the “Randomizer for Clinical Trials 1.8.1″ . Randomization is carried out after the patient has signed the informed consent and has been matched to a lay buddy, dependent on the place of residence.
In the first 10–12 weeks each couple (one buddy and one malnourished frail person) is divided randomly into the intervention and the control group.
Participants in the control group are visited twice a week by buddies, but they do not specifically monitor the nutritional status or perform physical training in the first 10–12 weeks. Instead of that, buddies are provided with a portfolio of possible activities, especially cognitive training, which they could perform together with the frail malnourished person. After 10–12 weeks the control group also receives nutritional intervention and the physical training for 3 months.
Buddies visit malnourished frail older persons twice a week for approximately one hour and they perform nutritional and physical activity interventions.
Activities for improving nutritional habit
The aim is to obtain adequate protein, energy and other nutrient intake, preferably by regular foods and beverages. Therefore, buddies discuss the following three main nutritional messages with the malnourished frail persons: fluid intake, animal and plant protein intake and energy intake. For this purpose, buddies are equipped with a portfolio in which the topics concerning physical activity and nutrition are explained in a straightforward manner. Moreover, they obtain ideas how to enrich food with protein and receive recipes of dishes which are protein and energy dense.
In order to show the variance of recommended and actual food intake, buddies are equipped with the “Healthy for Life Plate” which is a modification of the Health Eating Plate of the Harvard University . It consists of a play board and food-cards representing a variety of foods (Figure 2).
One food-card shows one portion size. Buddies and malnourished frail persons should set these food-cards, which they have eaten the day before, on the play board. The “Healthy for Life Plate” assesses the quantity and the composition of daily food rations. Therefore, with the game, dietary behavior can be examined and consequently optimize dietary habits. For convincing malnourished frail persons to change their nutritional habits, buddies additionally use motivational interviewing techniques . Due to this fact every nutritional message includes a section for individual goal setting and tools to reinforce the self-efficacy. As it is done in the motivational-volitions-concept , every message also includes a part which should reveal problems of implementing the goal in everyday life, in order to find solutions for them.
Twice a week strength training is performed by malnourished frail persons together with the buddies. The training comprises a warm-up (about five minutes, mobilization exercises) followed by six strength exercises, which are performed in circuit form with two sets. The exercises are conducted with 15 repetitions until muscular exhaustion. The performed exercises can be retained from Table 2. This circle lasts about 30 minutes. Moreover, buddies talk about the relevance of health enhancing physical activity in connection with frailty. Further on, they discuss possible arising problems, talk about their baseline activity and set individual goals concerning physical activity. For personal motivation buddies and frail people get a pedometer. Additionally, buddies advise the malnourished frail elderly to practice the same strength exercises once a week on their own.
Materials for the intervention group
Participants of the intervention group receive a bag which contains the following materials: a guidebook including messages regarding health promoting nutrition, detailed information on health enhancing physical activity and all strength exercises shown as pictures, a recipe book with dishes high in energy and protein, a dynaband for exercising, a demonstration DVD for guidance and motivation and a pedometer for counting food steps. Additionally, in the box there is the “Healthy for Life Plate”. Buddies are also equipped with a documentation book, where they should record the content of each home visit.
Training of the buddies
The project team, consisting of three sport scientists, two nutritional scientists and one medical doctor, trains the buddies of the intervention and the control group 4 times for 3 hours each session. This training starts 4 weeks before the first appointment with the malnourished frail persons will take place (Figure 3).
The sessions comprise lessons concerning aging, frailty, malnutrition, main nutritional messages, which are described in the section intervention group, and the importance of health enhancing physical activity, focusing on strength training and baseline activity. Moreover, buddies learn about the key issues of motivational interviewing skills. Buddies additionally get to know the interventions conducted with the control group. Training is designed interactively and enables buddies how to enrich dishes with regards to the energy and protein intake. They practice the motivational interviewing skills and can taste food. Furthermore, the project team exercises together with buddies in order to show them the right performance and intensity of each strength exercise and they discuss their pedometer data with them.
Two to three weeks after the beginning of the intervention, the buddies and the project team meet again to discuss arising questions and exchange experiences.
Buddies in the control group get another training to refresh their knowledge before they start with the nutritional and physical activity intervention after 10–12 weeks of the initial period.
All involved persons, malnourished frail elderly people and buddies, are evaluated at four points in time: before the intervention (AP1), after 10–12 weeks (AP2), after 6 months (AP3), and after 12 months (AP4). Malnourished frail persons are measured at their home and all buddies are surveyed after the last training of the buddies, respectively. Not all measurements take place at each time point. Table 3 gives a summary of the conducted measurements at several times (AP1, AP2, AP3, AP4) in malnourished frail elderly persons (F) and buddies (B).
The following measurements are performed:
Measurements of health status:
Quality of life assessed by the World Health Organization Quality of Life WHOQOL-BREF  and by 3 dimensions of the WHOQOL-OLD (“sensory functions”, “autonomy”, “activities in the past, present and future”) 
Social support measured with the short version of the questionnaire F-SozU .
Frequency of hospitalization
Frequency of falls
Documentation of fear of falling assessed by the FES-I (Falls Efficacy Scale-International Version) 
Measurements of frailty, nutritional status, physical activity:
Frailty status assessed by the SHARE-FI (Frailty Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe) . According to the results of the SHARE-FI, persons are categorized in frail, pre-frail, and robust people divided by gender. The handgrip strength, which is the primary endpoint of the study and part of the SHARE-FI, is measured with a hydraulic dynamometer in standardized procedure . For each side three attempts are made, and the highest one is used for calculation.
Nutritional status assessed by the long form of the MNA (Mini Nutritional Assessment) . In our study calf circumference is used which is measured with a tape at the sitting patient on the left and the right lower leg at the strongest circumference . Different to the protocol, persons put their feet on the floor while measuring.
Body mass index (BMI; kg/m 2 ) while body height is assessed by a yardstick and body weight by a calibrated scale.
Body composition assessed by the BIA (Bioelectrical Impedance Analysis) in standardized procedure . Moreover, waist circumference is measured at a vertical level 2.5 cm above the umbilicus while expiration .
Qualitative and quantitative contents of refrigerators assessed by a predefined protocol and picture of refrigerator .
Muscle strength assessed by the MASS (Measurement of age and sex related reference values of muscle strength) and the Concept 2 Dyno. The MASS is a new diagnosis system which was developed by the Technical University of Vienna. It evaluates health related concentric dynamic muscle strength. The measurement is velocity-independent and hence, is appropriate for the target group. Three exercises (bench press, bench pull, and leg press) will be conducted in standardized procedure. For all tested muscle groups the following parameters are recorded: maximum resistance with low velocity and 2–3 fix adjusted sub-maximum loads. Moreover, the Concept 2 Dyno is used for assessing the muscle strength. The same exercises as before will be conducted in standardized procedure .
Daily physical activity assessed by an activity sensor (pedometer), the modified PASE (Physical Activity Scale for the elderly)  and the modified questionnaire on health-related behavior FEG (Fragebogen zur Erfassung des Gesundheitsverhaltens) . The pedometer-data will be analyzed as follows: Data from the week before AP2, AP3 and AP4 will be included in the analysis. Data of those who have used the pedometer less than four days are excluded. Days, on which the pedometer was used less than eight hours, are considered as invalid. The number of steps below 90 steps per minute, the number of steps above 90 steps per minutes and the walk time is analyzed.
Balance and mobility components assessed by the SPPB (Short Physical Performance Battery) .
Laboratory parameters for malnutrition or frailty (albumin, total cholesterol, transferrin, triglyceride, 25-hydroxy-vitamin D, folic acid, CRP, IL-6, TNF-alpha and leucocytes)
Personal data e.g. age, gender, family status, education level, income, occupation
Measures of drop-out (DO): the drop-out rate between the first and second visit and until the final visit should be analyzed. For each case of discontinued participation (Ri), the following reasons are discriminated: medical reason (R1) and person’s own decision (R2), whereas an “A” stands for all participants who passed the baseline assessment.
Drop-outs between the first and second visit:
⋅DOR = DO1 + DO2 – all participants who drop out between the first and second visit
⋅DOR1 = DO1/A – percentage of participants who discontinue by medical reasons.
⋅DOR2 = DO2/A – percentage of participants who discontinue on their own decision. Members of this group are asked for a personal reason (voluntary and open question), and also be asked to participate in the final visit.
Drop-outs until the final visit
⋅|DOR| – total number of participants who drop out until the final visit
⋅IDORI = IDO1I + IDO2I – all participants who drop out until the final visit
⋅IDOR1I = IDO1I/A – percentage of participants who discontinue by medical reasons.
⋅IDOR2I = IDO2I/A – percentage of participants who discontinue on their own decision.
Measures of adherence are calculated as:
⋅Number of home visits
⋅Number of activity units, which have been done without buddies respectively without malnourished frail people
⋅Number of discussed nutritional messages
Expectations/Appraisal of the interventions by participant (malnourished frail persons and buddies): following questions are asked, “Would you once again participate in the trial? Why/why not?”. Participants, who completed the intervention, are asked to rate the content of the nutritional and physical activity interventions, the length of the program, and the frequency of home visits. Moreover, they should score (on a scale from one to five) the utility of the materials, which they received e.g. guidebook, dynabands, pedometers, training DVD or VHS, the “Healthy for Life Game” and questionnaires. Buddies should also rate the training sessions and the documentation book. Finally, concrete proposals for program improvements are asked, “Do you have any ideas or proposals for program improvements?”.
Documentation of any undesirable event during the intervention: Any symptom or any disease of a participant, which occurs during the intervention, is called an undesirable event . This definition is valid, whether this event is caused by the intervention or not. In case of an undesirable event, the participant promptly has to suspend nutritional and exercise units and they have to visit a physician. The event has to be documented by a standardized report protocol, including the following judgments: medical/non-medical, caused/not caused by exercises and people may/may not continue nutritional and exercise units.
Data exploration using descriptive statistical analysis and inferential statistics is performed. The sample data is carried out by frequencies or percentages, means and standard deviation, and graphics. 95% confidence intervals (CI) are calculated for the differences in percentages and medians. T-test and chi-square test is used to compare groups at baseline. Moreover, Pearson’s- and Spearman’s correlation coefficients is used. In order to test the normal distribution, histograms and box plots will be applied. If normal distributions are not met, non-parametric tests such as Wilcoxon, Mann–Whitney-U-Test and Kendall’s tau and Spearman’s correlation coefficients are chosen. Analysis of covariance (ANCOVA), comparing parameters after the intervention (AP2) and after the follow-ups (AP3, AP4) between intervention and control group, adjusting for the baseline value as covariate is performed. The IBM® SPSS® Statistics for Windows, Version 20 software (IBM Corp., Armonk, NY, U.S.) is used for all statistical analyses. All tests are two-sided and a p-value <0.05 is considered statistically significant.
The major strength of the proposed study design is the implementation of nutritional and physical activity interventions by trained lay buddies on malnourished frail people at their home environment. The results of previous studies on supervised strength training in frail persons demonstrate beneficial effects on risk of falls, balance or on gait ability [68–71]. Additionally, other studies examined the effects on home-based exercise programs supervised by therapists or home helpers [72–76]. Especially, Vestergaard S and colleagues showed in a randomized study a significant improvement of handgrip strength in community-dwelling frail older women, implemented by home-based video exercise training interventions . Furthermore, the randomized study by Bonnefoy M et al. demonstrates that the compliance rate of people who were supervised by people with lower qualification levels is not much lower than those who obtained an intervention by specially-trained nurses . Moreover, there are indications in the literature that the nutritional status is getting better after nursing home admission  and that an individualized nutritional counseling can improve their dietary habit of community-dwelling elderly person after discharge . On basis of these findings we are convinced that trained lay buddies are able to improve the health status of malnourished frail persons. An additional advantage of our study design is the need for malnourished frail people to leave their home, which might be an impeding factor for participating in such interventions. Furthermore, this designed study has the potential to improve the overall health status of buddies. Within the scope of the study, buddies experience the capability to prevent frailty and malnutrition by a balanced dietary pattern and physical activity. A reduction of isolation should be reached in both concerned parties.
A crucial point of the study is the compliance of both parties on regularly performing the strength exercises with correct intensity. Hence, all four buddy training sessions focus on this issue. Another crucial point is the ability of buddies to motivate frail malnourished persons to improve their nutritional habits. As the buddies are non-professionals, the nutritional interventions focus on the main “topics”. In detail, these topics contain information and recommendations on nutrition and additionally suggestions on the implementation in everyday life e.g. modified traditional recipes with tips on protein enrichment or portion sizes shown as handful in pictures.
The main objectives of these nutritional and physical activity interventions are the evaluation of the applicability of this program carried out by buddies and especially the sustainability that older people may live independently at home and as long as possible, which offers new methods for the management of frailty.
TED: medical doctor, associate professor at the Institute of Social Medicine, Centre for Public Health, Medical University of Vienna.
CL: sports scientist, SPORTUNION Austria, Department for Preventive Medicine.
SH: sports scientist and PHD-student at the Institute of Social Medicine, Centre for Public Health, Medical University of Vienna; sports scientist, SPORTUNION Austria, Department for Preventive Medicine.
EL: nutritionist and PHD-student at the Institute of Social Medicine, Centre for Public Health, Medical University of Vienna.
AK: sports scientist and PHD-student at the Institute of Social Medicine, Centre for Public Health, Medical University of Vienna.
ML: nutritionist at the Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University of Vienna and at the Special Institute for Preventive Cardiology And Nutrition SIPCAN.
KES: nutritionist at the Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University of Vienna.
Bioelectrical impedance analysis
Malnourished, frail, older persons
Fragebogen zur Erfassung des Gesundheitsverhaltens
Falls Efficacy Scale-International Version
Fragebogen zur sozialen Unterstützung
Measurement of age and sex related reference values of muscle strength
Mediterranean diet adherence screener
Mini mental state examination
Mini nutritional assessment
Mini nutritional assessment long-form
Mini nutritional assessment Short-Form
Physical activity scale for the elderly
Frailty instrument for primary care of the survey of health, ageing and retirement in Europe
Short physical performance battery
World Health Organization Quality of Life.
Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G: Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004, 59 (3): 255-263. 10.1093/gerona/59.3.M255.
Espinoza S, Walston JD: Frailty in older adults: insights and interventions. Cleve Clin J Med. 2005, 72 (12): 1105-1112. 10.3949/ccjm.72.12.1105.
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: 57-10.1186/1471-2318-10-57.
Santos-Eggimann B, Cuenoud P, Spagnoli J, Junod J: Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J Gerontol A Biol Sci Med Sci. 2009, 64 (6): 675-681.
Böck M, Rieder A, Dorner TE: vol. 41. Frailty. Definition, Erkennung und Bedeutung in der Gesundheitsförderung und Prävention. 2011, Linz: OÖ. Gebietskrankenkasse
Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, et al: Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people. Age Ageing. 2010, 39 (4): 412-423. 10.1093/ageing/afq034.
Espinoza SE, Fried LP: Risk factors for frailty in the older adult. Clin Geriatrics. 2007, 15: 37-44.
Sayer AA, Syddall H, Martin H, Patel H, Baylis D, Cooper C: The developmental origins of sarcopenia. J Nutr Health Aging. 2008, 12 (7): 427-432. 10.1007/BF02982703.
Thompson DD: Aging and sarcopenia. J Musculoskelet Neuronal Interact. 2007, 7 (4): 344-345.
Paddon-Jones D, Short KR, Campbell WW, Volpi E, Wolfe RR: Role of dietary protein in the sarcopenia of aging. Am J Clin Nutr. 2008, 87 (5): 1562S-1566S.
Morley JE: Sarcopenia: diagnosis and treatment. J Nutr Health Aging. 2008, 12 (7): 452-456. 10.1007/BF02982705.
Blaum CS, Xue QL, Michelon E, Semba RD, Fried LP: The association between obesity and the frailty syndrome in older women: the Women’s health and aging studies. J Am Geriatr Soc. 2005, 53 (6): 927-934. 10.1111/j.1532-5415.2005.53300.x.
Villareal DT, Banks M, Siener C, Sinacore DR, Klein S: Physical frailty and body composition in obese elderly men and women. Obes Res. 2004, 12 (6): 913-920. 10.1038/oby.2004.111.
Woods NF, LaCroix AZ, Gray SL, Aragaki A, Cochrane BB, Brunner RL, Masaki K, Murray A, Newman AB: Frailty: emergence and consequences in women aged 65 and older in the Women’s health initiative observational study. J Am Geriatr Soc. 2005, 53 (8): 1321-1330. 10.1111/j.1532-5415.2005.53405.x.
Soeters PB, Reijven PL, Van der Schueren MA VB-d, Schols JM, Halfens RJ, Meijers JM, Van Gemert WG: A rational approach to nutritional assessment. Clin Nutr. 2008, 27 (5): 706-716. 10.1016/j.clnu.2008.07.009.
Soeters PB, Schols AM: Advances in understanding and assessing malnutrition. Curr Opin Clin Nutr Metab Care. 2009, 12 (5): 487-494. 10.1097/MCO.0b013e32832da243.
Allison SP: Malnutrition, disease, and outcome. Nutrition. 2000, 16 (7–8): 590-593.
Davison KK, Ford ES, Cogswell ME, Dietz WH: Percentage of body fat and body mass index are associated with mobility limitations in people aged 70 and older from NHANES III. J Am Geriatr Soc. 2002, 50 (11): 1802-1809. 10.1046/j.1532-5415.2002.50508.x.
Dorner TE, Rieder A: Obesity paradox in elderly patients with cardiovascular diseases. Int J Cardiol. 2012, 155 (1): 56-65. 10.1016/j.ijcard.2011.01.076.
Dorner TE, Schwarz F, Kranz A, Freidl W, Rieder A, Gisinger C: Body mass index and the risk of infections in institutionalised geriatric patients. Br J Nutr. 2010, 103 (12): 1830-1835. 10.1017/S0007114510000152.
Locher JL, Roth DL, Ritchie CS, Cox K, Sawyer P, Bodner EV, Allman RM: Body mass index, weight loss, and mortality in community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2007, 62 (12): 1389-1392. 10.1093/gerona/62.12.1389.
Zizza CA, Herring A, Stevens J, Popkin BM: Obesity affects nursing-care facility admission among whites but not blacks. Obes Res. 2002, 10 (8): 816-823. 10.1038/oby.2002.110.
Guigoz Y, Vellas B, Garry PJ: Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev. 1996, 54 (1 Pt 2): 59-65.
Hubbard RE, O’Mahony MS, Calver BL, Woodhouse KW: Plasma esterases and inflammation in ageing and frailty. Eur J Clin Pharmacol. 2008, 64 (9): 895-900. 10.1007/s00228-008-0499-1.
Leng SX, Xue QL, Tian J, Walston JD, Fried LP: Inflammation and frailty in older women. J Am Geriatr Soc. 2007, 55 (6): 864-871. 10.1111/j.1532-5415.2007.01186.x.
Puts MT, Visser M, Twisk JW, Deeg DJ, Lips P: Endocrine and inflammatory markers as predictors of frailty. Clin Endocrinol. 2005, 63 (4): 403-411. 10.1111/j.1365-2265.2005.02355.x.
Walston JD: Frailty. UpToDate. [http://www.uptodate.com/contents/frailty],
Ble A, Cherubini A, Volpato S, Bartali B, Walston JD, Windham BG, Bandinelli S, Lauretani F, Guralnik JM, Ferrucci L: Lower plasma vitamin E levels are associated with the frailty syndrome: the InCHIANTI study. J Gerontol A Biol Sci Med Sci. 2006, 61 (3): 278-283. 10.1093/gerona/61.3.278.
Semba RD, Bartali B, Zhou J, Blaum C, Ko CW, Fried LP: Low serum micronutrient concentrations predict frailty among older women living in the community. J Gerontol A Biol Sci Med Sci. 2006, 61 (6): 594-599. 10.1093/gerona/61.6.594.
Harris D, Haboubi N: Malnutrition screening in the elderly population. J R Soc Med. 2005, 98 (9): 411-414. 10.1258/jrsm.98.9.411.
Neelemaat F: Post-discharge nutritional support in malnourished ill elderly patients – effectiveness and cost-effectiveness. 2012, Amsterdam, The Netherlands: VU University Medical Center
Beck AM, Kjaer S, Hansen BS, Storm RL, Thal-Jantzen K, Bitz C: Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge: a randomized controlled trial. Clin Rehabil. 2013, 27 (6): 483-493. 10.1177/0269215512469384.
Dorner T, Kranz A, Zettl-Wiedner K, Ludwig C, Rieder A, Gisinger C: The effect of structured strength and balance training on cognitive function in frail, cognitive impaired elderly long-term care residents. Aging Clin Exp Res. 2007, 19 (5): 400-405. 10.1007/BF03324721.
Perrig-Chiello P, Perrig WJ, Ehrsam R, Staehelin HB, Krings F: The effects of resistance training on well-being and memory in elderly volunteers. Age Ageing. 1998, 27 (4): 469-475. 10.1093/ageing/27.4.469.
Wolfson L, Judge J, Whipple R, King M: Strength is a major factor in balance, gait, and the occurrence of falls. J Gerontol A Biol Sci Med Sci. 1995, 50: 64-67.
Gomes GA, Cintra FA, Batista FS, Neri AL, Guariento ME, Sousa Mda L, D’Elboux MJ: Elderly outpatient profile and predictors of falls. Sao Paulo Med J = Rev Paul Med. 2013, 131 (1): 13-18.
Landi F, Liperoti R, Russo A, Giovannini S, Tosato M, Capoluongo E, Bernabei R, Onder G: Sarcopenia as a risk factor for falls in elderly individuals: results from the ilSIRENTE study. Clin Nutr. 2012, 31 (5): 652-658. 10.1016/j.clnu.2012.02.007.
Walston J, McBurnie MA, Newman A, Tracy RP, Kop WJ, Hirsch CH, Gottdiener J, Fried LP: Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the cardiovascular health study. Arch Intern Med. 2002, 162 (20): 2333-2341. 10.1001/archinte.162.20.2333.
Dorner T, Luger E, Tschinderle J, Stein K, Haider S, Kapan A, Lackinger C, Schindler K: Association between nutritional status (MNA®-SF) and frailty (SHARE-FI) in acute hospitalised elderly patients. J Nutr Health and Aging. In press
Dale O, Salo M: The helsinki declaration, research guidelines and regulations: present and future editorial aspects. Acta Anaesthesiol Scand. 1996, 40 (7): 771-772. 10.1111/j.1399-6576.1996.tb04530.x.
Schulz KF, Altman DG, Moher D: CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Int J Surg. 2011, 9 (8): 672-677. 10.1016/j.ijsu.2011.09.004.
Dorner TE, Tschinderle J, Schindler K: Frailty, Ernährungsstatus und Bereitschaft zu einer Trainings- und Ernährungsintervention bei älteren Personen in Wiener Krankenhäusern. Wien Klin Wochenschr. 2011, 123 (17–18): A40-A41.
Mueller M: Diploma Thesis. Pilotstudie zur Einführung eines Buddy-Systems in die Prävention und Therapie von Frailty. 2013, Vienna: Medical University of Vienna
Tschinderle J, Schindler K, Dorner T: Prävalenz von frailty und malnutrition bei personen über 65 jahren in wiener krankenhäusern. [http://www.pflegenetz.at/index.php?id=82&tx_ttnews%5Btt_news%5D=527&cHash=fc936f9e463b339fc487cd6d1315b4b8&print=1],
Randomizer for clinical trials 1.8.1. [https://www.meduniwien.ac.at/randomizer/web/login.php],
University H: Healthy eating plate. [http://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/],
Miller W, Rollnick S: Motivational interviewing: Preparing people for change, vol. 2002, New York: Guilford Press, 2
Göhner W, Fuchs R: Änderung des Gesundheitsverhaltens. MoVo Gruppenprogramme für körperliche Aktivität und gesunde Ernährung. 2007, Göttingen: Hogrefe
Group T: Development of the world health organization WHOQOL-BREF quality of life assessment. The WHOQOL group. Psychol Med. 1998, 28 (3): 551-558.
Winkler I, Matschinger H, Angermeyer MC: The WHOQOL-OLD. Psychother Psychosom Med Psychol. 2006, 56 (2): 63-69. 10.1055/s-2005-915334.
Fydrich T, Sommer G, Brähler E: Fragebogen zur Sozialen Unterstützung (F-SozU). Manual. 2007, Göttingen: Hogrefe
Dias N, Kempen GI, Todd CJ, Beyer N, Freiberger E, Piot-Ziegler C, Yardley L, Hauer K: The german version of the falls efficacy scale-international version (FES-I). Z Gerontol Geriatr. 2006, 39 (4): 297-300. 10.1007/s00391-006-0400-8.
Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, Cooper C, Sayer AA: A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach. Age Ageing. 2011, 40 (4): 423-429. 10.1093/ageing/afr051.
Kondrup J, Allison SP, Elia M, Vellas B, Plauth M: ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003, 22 (4): 415-421. 10.1016/S0261-5614(03)00098-0.
Vellas B, Villars H, Abellan G, Soto ME, Rolland Y, Guigoz Y, Morley JE, Chumlea W, Salva A, Rubenstein LZ, et al: Overview of the MNA-Its history and challenges. J Nutr Health Aging. 2006, 10 (6): 456-463.
Kessler J, Denzler P, Markowitsch HJ: DT Demenz-Test: Eine Testbatterie zur Erfassung kognitiver Beeinträchtigungen im Alter. Mini Mental Status Examination MMSE. German Version. 1990, Beltz-Verlag: Weinheim
Folstein MF, Folstein SE, McHugh PR: “Mini-mental state”. a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975, 12 (3): 189-198. 10.1016/0022-3956(75)90026-6.
Data Imput GmbH: Gebrauchsanleitung Jubiläumssonderserie BIA 2000 - S Bioelectrical Impedance Analyzer. [http://www.data-input.de/media/pdf-deutsch/Gebrauchsanleitung_BIA_2000S.pdf],
Guerra RS, Amaral TF, Marques EA, Mota J, Restivo MT: Anatomical location for waist circumference measurement in older adults: a preliminary study. Nutricion hospitalaria: organo oficial de la Sociedad Espanola de Nutricion Parenteral y Enteral. 2012, 27 (5): 1554-1561.
Schroder H, Fito M, Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Lamuela-Raventos R, Ros E, Salaverria I, Fiol M, et al: A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J Nutr. 2011, 141 (6): 1140-1145. 10.3945/jn.110.135566.
Kroke A, Klipstein-Grobusch K, Voss S, Moseneder J, Thielecke F, Noack R, Boeing H: Validation of a self-administered food-frequency questionnaire administered in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study: comparison of energy, protein, and macronutrient intakes estimated with the doubly labeled water, urinary nitrogen, and repeated 24-h dietary recall methods. Am J Clin Nutr. 1999, 70 (4): 439-447.
Boumendjel N, Herrmann F, Girod V, Sieber C, Rapin C-H: Refrigerator content and hospital admission in old people. Lancet. 2000, 356 (9229): 563-10.1016/S0140-6736(00)02583-6.
Marchart P: Diploma Thesis. Anthropometrisch- und Altersbezogene Referenzwerte für die Maximalkraft und Kraftausdauer bei Kindern (ab 12 J.), Jugendlichen und Erwachsenen. 2002, Vienna: University of Vienna
Washburn RA, Smith KW, Jette AM, Janney CA: The physical activity scale for the elderly (PASE): development and evaluation. J Clin Epidemiol. 1993, 46 (2): 153-162. 10.1016/0895-4356(93)90053-4.
Dlugosch GE WK: Fragebogen zur Erfassung des Gesundheitsverhaltens (FEG). 1995, Frankfurt: Swets Test Services
Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB: A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994, 49 (2): M85-M94. 10.1093/geronj/49.2.M85.
Hinrichs T, Bucchi C, Brach M, Wilm S, Endres HG, Burghaus I, Trampisch HJ, Platen P: Feasibility of a multidimensional home-based exercise programme for the elderly with structured support given by the general practitioner’s surgery: study protocol of a single arm trial preparing an RCT [ISRCTN58562962]. BMC Geriatr. 2009, 9: 37-10.1186/1471-2318-9-37.
Cadore EL, Rodriguez-Manas L, Sinclair A, Izquierdo M: Effects of different exercise interventions on risk of falls, gait ability and balance in physically frail older adults. A systematic review. Rejuvenation Res. 2013, 16 (2): 105-114. 10.1089/rej.2012.1397.
Sullivan DH, Roberson PK, Smith ES, Price JA, Bopp MM: Effects of muscle strength training and megestrol acetate on strength, muscle mass, and function in frail older people. J Am Geriatr Soc. 2007, 55 (1): 20-28. 10.1111/j.1532-5415.2006.01010.x.
Fiatarone MA, O’Neill EF, Ryan ND, Clements KM, Solares GR, Nelson ME, Roberts SB, Kehayias JJ, Lipsitz LA, Evans WJ: Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med. 1994, 330 (25): 1769-1775. 10.1056/NEJM199406233302501.
Seynnes O, Fiatarone Singh MA, Hue O, Pras P, Legros P, Bernard PL: Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. J Gerontol A Biol Sci Med Sci. 2004, 59 (5): 503-509. 10.1093/gerona/59.5.M503.
Matsuda PN, Shumway-Cook A, Ciol MA: The effects of a home-based exercise program on physical function in frail older adults. J Geriatr Phys Ther. 2010, 33 (2): 78-84.
Clegg A, Barber S, Young J, Forster A, Iliffe S: The home-based older People’s exercise (HOPE) trial: study protocol for a randomised controlled trial. Trials. 2011, 12: 143-10.1186/1745-6215-12-143.
Bonnefoy M, Boutitie F, Mercier C, Gueyffier F, Carre C, Guetemme G, Ravis B, Laville M, Cornu C: Efficacy of a home-based intervention programme on the physical activity level and functional ability of older people using domestic services: a randomised study. J Nutr Health Aging. 2012, 16 (4): 370-377. 10.1007/s12603-011-0352-6.
Gill TM, Baker DI, Gottschalk M, Gahbauer EA, Charpentier PA, de Regt PT, Wallace SJ: A prehabilitation program for physically frail community-living older persons. Arch Phys Med Rehabil. 2003, 84 (3): 394-404. 10.1053/apmr.2003.50020.
Hinrichs T, Moschny A, Brach M, Wilm S, Klaassen-Mielke R, Trampisch M, Platen P: Effects of an exercise programme for chronically ill and mobility-restricted elderly with structured support by the general practitioner’s practice (HOMEfit) - study protocol of a randomised controlled trial. Trials. 2011, 12: 263-10.1186/1745-6215-12-263.
Vestergaard S, Kronborg C, Puggaard L: Home-based video exercise intervention for community-dwelling frail older women: a randomized controlled trial. Aging Clin Exp Res. 2008, 20 (5): 479-486. 10.1007/BF03325155.
Dorner TE, Rieder A, Lawrence K, Jancuska A, Gisinger C: Prevalence of obesity in a geriatric long-term care facility. JNHA. 2006, 10 (72):
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/1232/prepub
The project has been funded by grants from the Vienna Science and Technology Fund. This is a non-commercial founds and has no role in study design, in the collection, analysis, interpretation and publication of data.
The project has been funded by grants from the WWTF (LS12-039). The authors declare that they have no competing interests.
TED is the principle investigator of the study, designed the study together with CL and KES, prepared the grant application and drafted the manuscript. EL, SH and AK are responsible for the elaboration and realization of the project. ML advised on editing and corrected the manuscript. All authors have read and approved the final version of the manuscript.
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Dorner, T.E., Lackinger, C., Haider, S. et al. Nutritional intervention and physical training in malnourished frail community-dwelling elderly persons carried out by trained lay “buddies”: study protocol of a randomized controlled trial. BMC Public Health 13, 1232 (2013) doi:10.1186/1471-2458-13-1232
- Physical activity
- Strength training