Growing old and becoming weak and frail often seem to go together. But frailty doesn’t have to be a consequence of growing old. And even for those who have begun showing signs of weakness, the condition can be turned around with better nutrition, exercise and greater social interaction.

For that reason, a team from Singapore General Hospital (SGH) and Sengkang General Hospital (SKH) has developed a simple but comprehensive screening programme to identify people aged 55 and older at risk of frailty.

The Individual Physical Proficiency Test for Seniors (IPPT-S) – much like the physical fitness test for national servicemen – assesses the flexibility, range of motion, strength, balance, coordination and endurance of older people, and is conducted in partnership with community partners and volunteers.

“While Singapore’s life expectancy is one of the highest in the world, people living longer may not be mirrored by them living healthier in old age, with the likelihood of the last 10 years of life being spent in disability,” said Dr Laura Tay, Senior Consultant, Department of General Medicine, SKH.

According to Associate Professor Ng Yee Sien, Senior Consultant, Department of Rehabilitation Medicine, SGH: “The development of frailty as one ages is very subtle, and often goes unnoticed until a health crisis occurs.

“Based on evidence-based practices, the IPPT-S programme aims to identify the robust, pre-frail and frail in the elderly living in the community, so that targeted interventions can happen [before they end up in hospital].”

A pilot run of the IPPT-S done in June-July 2017 and involving 100 senior residents in the Rivervale neighbourhood of Sengkang picked up a number of frail and pre-frail seniors. Prof Ng said 30 per cent of the participants were found to be in the pre-frail and 2 per cent in the frail stages.

A questionnaire – a part of the test that looks at nutritional status, ability to perform daily living activities, and other health aspects such as mood and cognition – found that more than 22 per cent were at risk of being malnourished, while more than 26 per cent might be depressed.

Both malnutrition and depression can significantly contribute to frailty. For instance, an elderly person who is malnourished is seven times more likely to suffer from frailty than someone who isn’t.

Studies have shown that frailty, when detected early, is reversible with lifestyle changes such as exercise,
nutritional support and cognitive interventions. “In other words, we can help these seniors make lifestyle
changes to nip any problems before their conditions get more complex,” said Prof Ng.

The IPPT-S provides an objective measure of the physical fitness of the elderly, and comprises nine tests that take about 30 to 40 minutes to complete.

For example, a six-minute walk gauges the level of endurance, while the 10m walk assesses strength and general physical health. The back-scratch test, where one hand reaches over the shoulder to touch the other which is placed behind the back, indicates upper limb flexibility.

Other tests include 30-second chair stands, a grip strength test, and a modified sit-and-reach test performed while seated on a chair.

Upon completing the programme, participants receive a Pass, Silver or Gold award and a health booklet of their results. Those who do not meet the “Pass” requirements are considered to be frail or pre-frail, and will be referred to primary health or specialist care for further assessment and follow-up.

In the next three years, the team hopes to reach out to at least 2,000 seniors living in the eastern part of Singapore that the SingHealth Regional Health Systems serve.

Social services like AMKFSC, which was a partner in the pilot project, will play a vital role in community screening activities, said Prof Ng.

“From the word ‘go’, we wanted to work with community partners like AMKFSC for both screening and post-
screening follow-up activities,” he said, adding that these organisations will conduct the IPPT-S at their senior activity and day rehabilitation centres in housing estates for the convenience of their residents.

Community partners and volunteers will also be trained to follow up with participants, including running structured exercise and nutrition programmes co-developed with SKH.

Frailty red flags

A frail older person may experience three or more of the following symptoms, said Associate Professor Ng Yee Sien, Senior Consultant, Department of Rehabilitation Medicine, SGH. Those who experience one or two signs are considered to be in the pre-frail stage.
• Unintentional weight loss of at least 4.5kg in the past year
• Feeling weak, having difficulty standing or climbing stairs unassisted 
• Feeling so exhausted that every task feels like it requires a huge effort
• Low level of physical activity, including things such as housework and exercise
• Slow walking speed