Promoting Autonomy Through ExerCisE (PACE) in Outpatient Geriatric Clinics

Physical inactivity (<150 minutes of physical activity (PA)/week) affects more than 75% of community-dwelling older adults, and this proportion increases to 90% among those living in residential settings. This behavior, which is the fourth leading risk factor for mortality, is also known to accelerate declines in functional capacity and physical performance. As a result, a negative cycle develops: following these declines, older adults may stop going out and become socially isolated, leading to further physical decline, reduced quality of life, and related mental health problems (stress and anxiety).

After the age of 65, older adults will spend, on average, 50% of their remaining lifetime living with physical disabilities. This loss of independence reduces their quality of life, social participation, and ability to remain at home.

These declines have consequences for home-care and healthcare systems. As a result of these declines, older adults may move into private seniors' residences (RPA; 18% in Quebec) or intermediate resources (RI; 8,817 places occupied by older adults), where levels of physical inactivity are exacerbated, increasing from 60% to 90%.

Unfortunately, the COVID-19 pandemic has exacerbated this problem, as it has forced older adults to remain at home or receive fewer home-care services due to restrictions on activities and physical/social distancing. As a result, they may remain inactive for an unknown period of time, creating a stressful situation.

One of the reasons for the high levels of physical inactivity and sedentary behavior among older adults is that the implementation of mobilizing activities is not part of routine care or service practices in outpatient geriatric clinics (OGC). Staff and managers in these settings have identified several barriers, including a lack of familiarity, human resources, knowledge, or skills related to these interventions, as well as anticipated challenges regarding the allocation of the human resources required.

Helping address the major challenge of maintaining older adults' health and preventing the accelerated deconditioning caused by isolation measures implemented to protect them from COVID-19 is a priority identified in the COVID-19 Ministerial Plan, through the Action Plan for a Second Wave, Axis 2, Action 3: prevention of deconditioning and supporting healthy aging at home.

This is precisely what this project, through the PACE tool, aims to achieve. Finally, in addition to older adults at risk, Quebec has 1.7 million informal caregivers, 58% of whom provide care to adults aged 75 and older. Unfortunately, this role is not without challenges, as caregiving is recognized as an important source of stress for caregivers who must cope with the declining health of an older adult and may consequently experience a deterioration in their own quality of life. The COVID-19 pandemic appears to have exacerbated this burden.

Previous studies conducted by our research team have shown that the implementation and use of specific and tailored PA programs are feasible, acceptable, and effective in older adults following hospitalization, resulting in improvements in walking speed, balance, and other physical outcomes. Furthermore, these studies showed that unsupervised prescription of adapted and individualized PA is not a concern, as it does not increase the risk of falls. Most importantly, for the implementation of such a practice, these programs were considered by the healthcare team to be easy to integrate into routine care/services and relevant to their mission. Their implementation was also feasible and beneficial, including in COVID-19 units.

The development of the PACE tool (Promouvoir l'Autonomie par l'exerCicE [Promoting Autonomy through Exercise]) is based on the same pragmatic and co-construction approach, incorporating the perspectives of healthcare settings through consultation with geriatric care clinicians (OGC) regarding usual practices, available resources, barriers, and limitations, as well as the perspectives of older adults and their informal caregivers regarding their expectations for PA. The tool includes 35 PA programs tailored to frail older adults who continue to live in the community. These programs are prescribed by a healthcare professional using a decision tree based on simple clinical criteria.

Furthermore, among older adults, dyadic interventions (older adult and informal caregiver) are associated with greater adherence to PA. The positive effects of PA on older adults' health can therefore be enhanced, leading to improved physical autonomy and reduced assistance requirements for informal caregivers, which is a government priority.

In addition, more than 60% of older adults and 80% of informal caregivers own connected devices such as a computer, tablet, or smartphone and regularly use the internet. Consequently, during the first wave of the COVID-19 pandemic, our research group implemented a protocol to remotely assess and monitor older adults' objective and subjective physical health in a valid and safe manner using the ZOOM© platform. Therefore, this remote, interactive virtual delivery model will not be a barrier to implementation and will make it possible to reach isolated older adults who require support.

Thus, the main objective of the project is to implement a best practice-daily prescription of adapted PA using the PACE tool in the outpatient geriatric clinics of the Institut Universitaire de Gériatrie de Montréal (IUGM) in order to counteract deconditioning while also reducing the workload on human resources.