Researchers found that 10 weeks of supervised outdoor walking or simple weekly reminders helped older adults lower frailty. Still, the improvements vanished after winter, highlighting the challenge of keeping older adults active year-round.
Study: The impact of outdoor walking interventions on frailty among older adults with mobility limitations: Findings from the Getting Older Adults Outdoors (GO-OUT) study. Image credit: PeopleImages/Shutterstock.com
A recent study in PLOS ONE investigated the effects of an outdoor walking intervention on reducing frailty among community-dwelling older adults with mobility limitations.
Frailty: Symptoms and assessments
Frailty is a medical condition in which multiple body systems lose their physiological reserve and function, leading to increased vulnerability to stress, illness, and injury. This condition is commonly associated with older adults.
Scientists have developed various strategies to assess frailty, among which Fried’s frailty index is most frequently used in research and clinical settings. Fried’s model evaluates frailty as a physical phenotype consisting of five indicators: exhaustion, unintentional weight loss, muscle weakness, low physical activity, and slow walking speed.
Fried’s frailty index categorizes individuals as non-frail (0 indicators), pre-frail (1 or 2 indicators), or frail (3 or more indicators). A frail individual is at a higher risk of falls, hospitalization, institutionalization, and premature mortality. Several studies have demonstrated that frailty is dynamic and reversible in nature. Therefore, developing strategies to delay or attenuate frailty among older adults is essential.
Strategies to reverse frailty
Many studies have shown that varied exercise types, such as resistance, aerobic, balance, and flexibility training, significantly enhance physical performance and mitigate frailty among community-dwelling older adults and those in long-term care facilities. In the U.S., walking and jogging are regarded as the most popular forms of exercise among the older population.
Walking in an outdoor environment has shown greater potential in mitigating frailty than indoor walking. A previous study highlighted that outdoor Nordic walking has greater benefits than general exercise with respect to reducing weakness, lower extremity strength, and depression in frail older adults aged 70 years and older. There is a need for broader intervention strategies to promote long-term behaviour change to alleviate frailty among older populations.
About the study
The Getting Older Adults Outdoor (GO-OUT) study is a two-parallel-group randomized trial conducted across four large Canadian cities, which investigated the effects of two behavioural interventions on improving frailty outcomes.
Participants were asked to attend a day educational workshop and a 10-week, park-based, supervised, outdoor walk group (OWG) program. The study design also included a 10-week weekly reminders (WR) program to promote outdoor walking activity among older adults with mobility limitations. The current study aimed to assess whether a 10-week OWG program or a 10-week WR program reduced frailty in community-dwelling older adults with mobility limitations.
The OWG consisted of two one-hour sessions each week for 10 weeks, resulting in a maximum of 20 sessions. Each session was group-based, structured, and held in large neighbourhood parks. Walking distances were progressively increased each week, and different walking skills were emphasized. Relevant data were collected at baseline (0 months), 3 months, 5.5 months, and a planned 12-month follow-up. However, frailty outcomes at 12 months could not be analyzed due to COVID-19 disruptions. Participants assigned to the WR group received a phone call every week for 10 weeks to encourage them to continue physical activity.
Participants aged 65 years or older, living independently in the community and experiencing difficulty walking outdoors, were included. Every participant must be able to walk at least 50 meters independently, with or without using a walking aid. Any participant who self-reported physical activity for 150 minutes or more was excluded.
Study findings
The mean age of the study cohort was 74.5 years, and most participants were female. Approximately 44% of the cohort had obtained a bachelor’s degree or higher. At baseline, both intervention groups had nearly identical participant characteristics.
Participants in the OWG attended a median of 13 sessions out of 20, while participants in the WR group received a median of 9 reminders out of 10 over the 10-week intervention period. The median time of outdoor walking at baseline, 3 months, and 5.5 months was 22.56 minutes, 13.04 minutes, and 0 minutes in the OWG, respectively, and 24.00 minutes, 26.07 minutes, and 0 minutes in the WR group, respectively.
Approximately 80% of participants remained in the study at 3 months, which reduced to 70% at 5.5 months. Retention rates were similar across both intervention groups.
Multivariable logistic regression analyses revealed that withdrawals were more prominent among participants from site 1, those with higher body mass index (BMI), and enrolled in the 2019−20 cohort. It must be noted that the intervention group and frailty status were not significant predictors of withdrawal.
Out of 5, the mean frailty sum scores at baseline were 0.98, 0.82 at 3 months, and 0.95 at 5.5 months. At baseline, approximately 34% of participants were classified as non-frail, 59% as pre-frail, and 7% as frail. However, at 3 months of intervention, the proportion of non-frail participants increased to 45%, while the number of pre-frail and frail participants decreased to 49% and 5%, respectively. By 5.5 months, the number of non-frail participants reduced to 40%, while pre-frail and frail participants increased to 51% and 9%, respectively.
No significant difference in frailty sum scores or phenotypes was detected in both the intervention groups throughout the study period. However, the paper noted that the OWG and WR groups showed distinct patterns in specific frailty indicators: OWG participants improved in weakness and slowness, while WR participants improved in weakness and low activity. These differences reflect task-specific pathways, with OWG emphasizing structured outdoor walking skills and WR reinforcing daily activity habits.
From baseline to 3 months, approximately 50% of the cohort maintained their frailty status, 16.1% improved, and 8.1% transitioned to a more severe state. By 5.5 months, improvements dropped to 8.9%, while worsening transitions increased to 20.5%. From baseline to 3 months of intervention, weakness decreased from 47% to 42%, and from 36% to 28% in OWG and WR interventions, respectively.
Fried’s frailty sum scores decreased by an average of 0.13 points across participants from both intervention groups from baseline to 3 months. However, no change in frailty status was observed from baseline to 5.5 months. The authors attributed this decline partly to seasonal effects, as the 5.5-month follow-up occurred during cold Canadian winter months when outdoor walking was especially difficult. They also noted that participants in the OWG often faced barriers such as illness, transportation challenges, or weather-related session cancellations, which limited adherence.
Conclusions
In sum, behavioural interventions aimed at improving outdoor walking among older adults with mobility limitations showed a short-term reduction in frailty. However, neither the supervised outdoor walk intervention nor the telephone weekly reminder intervention was superior.
The study also highlighted that each program may reduce frailty through different mechanisms, suggesting that diverse strategies may be needed to address frailty in practice.
Concerning the study's limitations, the COVID-19 pandemic could have hampered frailty data collection. Additionally, the effect of a particular intervention could not be isolated because some participants in both groups reported receiving co-interventions. The authors further emphasized that the observed benefits were not sustained beyond the intervention period, underscoring the need for year-round, multi-component approaches, such as combining exercise, nutrition, behavioural support, and social engagement, to maintain frailty improvements.
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