Prevent frailty- a public health mandate

There are few guarantees in life. One for sure – we get old unless we die young. And getting old is interesting because there are guarantees there too. If you don’t stay strong, you get frail.

“Frailty” – what is it?

Globally, we are getting older and frailer [1-3]. Frailty isn’t fun. It’s a lonely experience [4] that affects more women than men [5] and is linked to poverty [6].? And it’s hard on your pocket – if you are frail, healthcare is 75% more expensive [7]. You are more likely to fall and break bones, go to hospital and stay longer, lose independence [8-11], cognitively decline [12], become delirious and need more care when you get out of hospital [13]. Half of all people over 85 are frail [9] and nearly 2 in 5 frail people die in hospital [13].

Is frailty inevitable or is it preventable?

Here’s the good news. Exercise that increases muscle strength (called “resistance” or “strength” training) can prevent frailty and even reverse it [14, 15]. It consistently improves and offsets age-related declines in strength and power and is linked to reductions in all-cause and cancer-related mortality, reductions in heart disease, high blood pressure, anxiety and depression [16].

If that is the case, why do only 6% of Australian adults over 50 do it [17]?

My own experience

A few years ago, I would have shrunk into a small invisible ball if someone told me I would enjoy and even thrive with gym-based strength training. ”No-ooo-ooo-oooo” you would have heard as I rolled away as fast as I could.

Besides, my problem is time.?

I enjoy a meaningful and productive life. I like to spend time with my husband and my children and grandchildren, all are a great source of love and joy. I also prioritise a wise mum who, now an older Australian, needs me and I need her.? Oh, and I also work full-time and this is another source of joy and wonder. I love my work.

In juggling all these priorities in my life I can sometimes leave myself behind and forget that I am only able to do all this stuff if I stay well, strong and connected. I need to find effective ways of getting the most benefit for the time I have available, and I also need something which I want to do.?

How did I come to be enrolled in a precisely-personalised, professionally-supervised and enjoyable program that has seen me increase my overall strength in just 8 months from the 20th to the 70th percentile for my gender and age, that takes exactly one hour (two half hour sessions) in total each week?

It was random. I heard about it and, as I was recovering from orthopaedic surgery that required some rehab, I enrolled.

To be honest, I have historically struggled with my motivation to go to a gym. I get bored. It delights me that there is evidence that each time I train with (and have an ongoing conversation with) my 20-something-year-old exercise scientist trainer, I benefit [18]. He makes sure my technique is safe [19], and encourages me, and importantly our conversations are meaningful (and he distracts me!).

A public health argument

Anyway, I can’t help thinking about my privilege to be able to access this life-enriching anti-frailty health and wellbeing service. I can afford it. I can invest in my future health and wellbeing, without fear of injury and while being involved in the intergenerational benefits of being around a bunch of young career professionals.

But what if it were available to a larger group of my peers? I got my head into the research to find the evidence for precision strength training, and also the potential cost-saving arguments backing it up.? Some of what I found out I have shared here.

In Australia we spend a lot on health ($9,365 per person 2021-2022) [20] but only $89 per person (just over 1%) to prevent ill-health [21].? Wow. This seems hugely skewiff to me.

I couldn’t find the whole picture about the cost of frailty across the Australian research - so, based on the available data, I did some back-of-the-envelope calculations to get an idea of what we spend once I get to the frail end of the spectrum, and it shocked me. I looked only at 85+ and took the most conservative estimate (line 5 in table).

We spend more than half a billion dollars in Australia on me and my peers once I am over 85 and have become frail and need to go to hospital. That’s just hospital. It doesn’t include my increased need for aged care services and accommodation due to frailty – think medications, think staff to look after me – the list goes on. And this expenditure is more than five times greater than at any other time in my life – if I am frail.

So, what do we, the taxpayers, invest in preventing frailty?

So I ask the question, if we spend this much after I have become frail - and the picture I am seeing is pretty miserable – what do we invest in my strength to keep me strong? The answer? Almost nothing. I pay for my own strength training but I know people who cannot. Mmmm. This is a question of equity, surely?

The public health argument

So … I come back to my original question: Why do only 6% of Australian adults over 50 do strength training?

My own theory based on this evidence review is that firstly, people may not know that just one hour a week of precise, individualised and professionally supervised strength training can prevent frailty and all its costly, miserable consequences. This type of strength training is not boring, dangerous or too time consuming. Secondly, we, the taxpayers, are spending a lot on sending very unwell and frail people to hospital but very little on preventing them from getting frail in the first place. We have not thought this through.

I and others [26] believe there is a public health argument for making individualised, precise and supervised strength training available to more of us. ?

Why don’t we? Think of our taxpayer savings were we to prevent frailty. What could we better invest in? A comprehensive dental care scheme that is part of Medicare? Don’t get me started …

Rowena Tagaloa Sydney North Health Network Monique Pockran

Raj Verma Anthony Brown Christina Johns Jasmine Glennan Tara Lee

Kean-Seng Lim Jay Rebbeck Are Tiki

Chronic Pain Australia Fiona Hodson Elfa Moraitakis Benjamin Graham

Hunter New England and Central Coast PHN Owen Hynes

?References

1. Proietti, M. and M. Cesari, Frailty: what is it? Frailty and Cardiovascular Diseases: Research into an Elderly Population, 2020: p. 1-7.
2. Wang, C.-H., et al., Health literacy and exercise to treat frailty in community-dwelling older adults: a national survey study. International journal of environmental research and public health, 2022. 19(14): p. 8711.
3. Subías-Perié, J., et al., Health economic evaluation of exercise interventions in people over 60 years old: A systematic review. Experimental Gerontology, 2022. 161: p. 111713.
4. Aminu, A.Q., Putting ageism in context: examining the relationship between age discrimination and frailty among older individuals aged 65 years and over. 2022.
5. Thompson, M.Q., et al., Frailty prevalence in Australia: findings from four pooled Australian cohort studies. Australasian journal on ageing, 2018. 37(2): p. 155-158.
6. Hayajneh, A.A. and M. Rababa, The association of frailty with poverty in older adults: a systematic review. Dementia and Geriatric Cognitive Disorders, 2022. 50(5): p. 407-413.
7. Salinas-Rodríguez, A., et al., Healthcare costs of frailty: implications for long-term care. Journal of the American Medical Directors Association, 2019. 20(1): p. 102-103. e2.
8. Morley, J.E., et al., Frailty consensus: a call to action. Journal of the American Medical Directors Association, 2013. 14(6): p. 392-397.
9. Clegg, A., et al., Frailty in elderly people. The lancet, 2013. 381(9868): p. 752-762.
10. Curtis, M., et al., Associations between body mass index and probable sarcopenia in community-dwelling older adults. Nutrients, 2023. 15(6): p. 1505.
11. Block, H., et al., Frailty in older people: Rehabilitation Treatment Research Examining Separate Settings (FORTRESS): protocol for a hybrid type II stepped wedge, cluster, randomised trial. BMC geriatrics, 2022. 22(1): p. 527.
12. Boyle, P.A., et al., Physical frailty is associated with incident mild cognitive impairment in community‐based older persons. Journal of the American Geriatrics Society, 2010. 58(2): p. 248-255.
13. Darvall, J.N., et al., Routine frailty screening in critical illness: a population-based cohort study in Australia and New Zealand. Chest, 2021. 160(4): p. 1292-1303.
14. Alkhodary, A., et al., The economic burden of frailty among elderly people: a review of the current literature. Malaysian Journal of Public Health Medicine, 2020. 20(2): p. 224-232.
15. Hoogendijk, E.O., et al., Frailty: implications for clinical practice and public health. The Lancet, 2019. 394(10206): p. 1365-1375.
16. Fyfe, J.J., D.L. Hamilton, and R.M. Daly, Minimal-dose resistance training for improving muscle mass, strength, and function: a narrative review of current evidence and practical considerations. Sports Medicine, 2022. 52(3): p. 463-479.
17. Bennie, J.A., J. Shakespear-Druery, and K. De Cocker, Muscle-strengthening exercise epidemiology: a new frontier in chronic disease prevention. Sports medicine-open, 2020. 6: p. 1-8.
18. Gadomska-Lila, K., Effectiveness of reverse mentoring in creating intergenerational relationships. Journal of Organizational Change Management, 2020. 33(7): p. 1313-1328.
19. Fisher, J., et al., Primum non nocere: A commentary on avoidable injuries and safe resistance training techniques. Journal of Trainology, 2014. 3(1): p. 31-34.
20. Australian Institute of Health & Welfare. Health expenditure Australia 2021-2022. 2021-2022; Available from: https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2021-22/contents/overview/health-spending-per-person.
21. Jackson, H. and A. Shiell, Preventive health: how much does Australia spend and is it enough? 2017.
22. Australian Institute of Health & Welfare, Australia's hospitals at a glance. 2023, AIHW: Canberra.
23. Australian Bureau of Statistics. Patient Experiences. 2022-2023; Available from: https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release#cite-window1.
24. Fairhall, N., et al., Economic evaluation of a multifactorial, interdisciplinary intervention versus usual care to reduce frailty in frail older people. Journal of the American Medical Directors Association, 2015. 16(1): p. 41-48.
25. Australian Bureau of Statistics. National, state and territory population. 2023; Available from: https://www.abs.gov.au/statistics/people/population/national-state-and-territory-population/latest-release#cite-window1.
26. Sundell, J., Resistance training is an effective tool against metabolic and frailty syndromes. Advances in preventive medicine, 2011. 2011.

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