Nutrition and Physical Activity for Older Adults

Prepared by: LP Iuliu Hațieganu University of Medicine and Pharmacy - (UMFCJ), Romania

I. INFORMATION ABOUT THE TRAINING PROGRAMME

I.1. Training name

I.2. General description

Older age is characterized by numerous physical, mental, and psycho-social changes that can expose older adults to increased risk of morbidity and mortality. The frailty syndrome, characterised by loss of muscle strength and impaired physical function, and associated with increased falls, hospitalisation and death has a worldwide prevalence of 5-27% among those aged 65 years and older¹. Nutritional deficiencies and low physical activity (PA) are common in this age group due to ill health, disability and reductions in enthusiasm, food intake and therefore, energy availability. Both low physical activity and inadequate dietary intake have a significant role to play in the onset and progression of frailty, primarily through bone and muscle health implications. The socio-economic aspects also play an important role in the choices of food and being physically active in this age group, especially in the Eastern-European countries.
The current module will present:

The problematic of deficient nutrition in older adults: prevalence, main causes, and negative health impact
The problematic of low physical activity in older adults: prevalence, main causes, and negative health impact
Nutritional recommendations for older adults
Physical activity recommendations for older adults
The use of technology to support health & care takers in the identification and management of poor nutrition and low physical activity in older adults

I. 3. Objectives of the training and expected learning outcomes

Objectives of the training:

Raise awareness of health & care workers regarding the importance of adequate nutrition and physical activity in older adults
Increase the knowledge level of health & care workers regarding methods for assessment of poor nutrition and inadequate physical activity levels (including the risk of frailty)
Increase skills level of health & care workers regarding methods (including modern technology instruments such as mobile apps) for identification of poor nutrition and low PA and delivery of adequate nutrition and PA interventions.

Expected learning outcomes
By the end of the module, the participants will be able to:

Understand the negative impact of poor nutrition and low PA on the older adults population (including frailty, multi-morbidity and mortality)
Understand the importance of assessment of poor nutrition, low PA and frailty risk
Be able to conduct (with or without assistance/collaboration) nutrition and PA assessment and frailty risk assessment.
Be able to conduct (with or without assistance/collaboration) interventions to promote adequate nutrition and PA in older adults
Be knowledgeable in using modern technology applications (such as mobile apps) for assessment of poor nutrition & PA and / or interventions to improve nutrition and PA in older adults.

I. 4. Target group – needs and input of target groups

The main barriers to get connected and effectively use internet services are lack of knowledge & skills, affordability, accessibility and lack of awareness.

I.4.1. Enrolment criteria

The module has no enrolment criteria.

I.4.2. Target group description and characteristics

The main target group for this module comprises health & care workers from inpatient and outpatient older adults care settings such as community day centres, retirement facilities etc.
A second target group is individual care takers, either family members or employed personnel, involved in home nursing or home care services.
A third target group is older adults that should be aware about the importance of adequate nutrition and PA to avoid frailty and maintain independence and mobility for as long as possible.

I.4.3. Duration

6 hours

I.4.4. Format

Online training

I.4.5. Module structure

The module will comprise 3 sub-modules lessons, as follows:

Lesson 1: Prevalence, causes and health risks associated with poor nutrition and low PA in older adults
Lesson 2: Assessment of poor nutrition and low PA in older adults and of health associated risks – frailty
Lesson 3: Nutrition and PA interventions in older adults

I.4.6. Learning methods

Asynchronous online learning – based on lectures prepared and uploaded on the platform in advance, reading materials, quizzes and other support materials

II. CONTENTS OF THE TRAINING PROGRAMME

Lesson 1: Prevalence, causes and health risks associated with poor nutrition and low PA in older adults

Adequate nutrition is important in every life stage, therefore the saying: “you are what you eat.” In the small children and young aged nutrition is a building block for physical and mental development while in adults it provides the necessary energy to fulfil daily tasks. But in the older adults population nutrition, or, better said, the inadequacies in nutrition can have a massive negative impact on numerous organs and systems. In brief, some of the health problems caused by a poor nutrition can include:

a weakened immune system, which increases the risk of infections
poor wound healing
muscle weakness and decreased bone mass, which can lead to falls and fractures
a higher risk of hospitalization
an increased risk of death

Malnutrition is generally defined as either too little food or a diet lacking in the right nutrients (undernutrition) or getting more nutrients than needed (overnutrition). However, in the older adults population malnutrition is more complex than just what is present or not on the plate (or excessive). In this age group, a poor diet can be caused by a combination of physical, social and psychological issues, each one playing a role in providing a proper senior nutrition.

Normal age-related changes: Taste, smell and appetite generally decline with age, making it more difficult to enjoy eating and keep regular eating habits.
Illness: Disease-related inflammation and illnesses can contribute to declines in appetite and changes in how the body processes nutrients.
Trouble eating: Difficulty chewing or swallowing, poor dental health, or losing the dexterity required to use tableware can make eating less enjoyable and cause discomfort.
Dementia: Behavioral or memory problems from Alzheimer’s disease or a related dementia can result in forgetting to eat, not buying groceries or other irregular food habits.
Medications: Some medications can affect appetite and nutrient absorption.
Restricted diets: Dietary restrictions for managing medical conditions — like limits on salt, fat or sugar — can also contribute to inadequate eating or not knowing what to eat.
Limited income: If you’re taking expensive medications, nutrient-rich foods can seem too expensive.
Reduced social contact: Having to constantly eat alone can cause you to enjoy mealtime less and/or lose interest in cooking and eating.
Limited access to food: If you can’t drive or have trouble walking, you may find it difficult to go shopping.
Depression: Grief, loneliness, failing health, lack of mobility, and other factors might contribute to depression, which can cause a loss of appetite.
Alcoholism: Too much alcohol can interfere with the digestion and absorption of nutrients. It can also result in poor eating habits².

Undernutrition is common among older people over 60 years of age. The prevalence of undernutrition in older people living in the community ranges between 1.3% and 47.8% (1–5). The reported prevalence is much higher in studies from low- and middle-income countries than high-income countries³.

Malnutrition is also a significant contribution to frailty, a syndrome defined as defined as a compromised ability to cope with everyday stressors due to aging-associated functional decline in multiple physiological systems The prevalence of frailty in community-dwelling elderly, defined as those aged over 65 years, ranges between 4.9% and 27.3% worldwide, with pre-frailty ranging from 34.6% to 50.9%. Frailty is characterised by loss of muscle strength and impaired physical function, and is associated with increased falls, hospitalisation and death¹. Therefore, it is important to identify the frail older adults and intervene, with complex interventions that include nutritional assessment and advice, in order to reverse the frailty status and its associated risk and increase the lifespan and the quality of life.
Nutritional advices for older adults include:

Eat a wide variety of foods from the five food groups: plenty of colourful vegetables, legumes/beans; fruit; grain (cereal) foods, mostly wholegrain and high fibre varieties; lean meats and poultry, fish, eggs, tofu, nuts and seeds; milk, yoghurt, cheese or their alternatives, mostly reduced fat.
Drink plenty of water – six to eight cups of fluid per day.
Limit foods high in saturated fat, such as biscuits, cakes, pastries, pies, processed meats, commercial burgers, pizza, fried foods, potato chips, crisps and other savoury snacks.
Replace high fat foods containing mostly saturated fat with foods containing mostly polyunsaturated and monounsaturated fats. Swap butter, cream, cooking margarine, coconut and palm oil with unsaturated fats from oils, spreads, nut butters and pastes, and avocado.
Limit foods and drinks containing added salt, and don’t add salt to foods in cooking or at the table.
Limit foods and drinks containing added sugars, such as confectionery, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks.
Limit alcohol. (Drink no more than two standard drinks a day.)
Keep ‘extras’ or ‘sometimes foods’ to a minimum – they’re not a regular part of a healthy diet. Extras are the high sugar, high fat, high salt foods listed above, such as commercial burgers, pizza, alcohol, lollies, cakes and biscuits, fried foods, and fruit juices and cordials⁵.

Physical activity (PA) in older adults is critically important for the prevention of disease, maintenance
of independence and improvement of quality of life. Some of the many benefits of regular exercise for older people include:

Muscle strength – the amount and size of muscle fibres decreases with age. Some studies suggest that the average body loses around 3kg of lean muscle every decade from middle age. The muscle fibres that seem to be most affected are those of the ‘fast twitch’ (phasic) variety, which govern strength and speedy contraction. There is evidence to suggest that these changes are related to a sedentary lifestyle, rather than age. Muscle mass can increase in the older person after regularly exercising for a relatively short period of time.
Bone strength – bone density begins to decline after the age of 40, but this loss accelerates around the age of 50 years. As a result of this bone loss, older people are more prone to bone fractures. Exercise may help to reduce the risk of bone loss and osteoporosis. Weight-bearing exercise, in particular, helps to keep bones healthy and strong.
Heart and lungs health – moderate intensity exercise is most favourable: for example, exercising at about 70 per cent of the individual’s maximum heart rate (220 beats per minute minus your age). Studies show that cardiorespiratory fitness takes longer to achieve in an older person than a young person, but the physical benefits are similar. Regardless of age, people are able to improve their cardiorespiratory fitness through regular exercise.
Joints integrity and mobility – the joints of the body require regular movement to remain supple and healthy. In particular, people with arthritis can benefit from aerobic and strengthening exercise programs.
Decreased body fat levels – carrying too much body fat has been associated with a range of diseases including cardiovascular disease and diabetes. Regular exercise burns kilojoules, increases muscle mass and speeds the metabolism. Together, these physiological changes help an older person maintain an appropriate weight for their height and build⁵.

The World Health Organization and U.S. Department of Health and Human Services guidelines recommend that older adults participate in at least 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent combination of each per week. Older adults should also engage in strengthening activities that involve all major muscle groups at least two days a week. Those at risk of falling should add exercises that help maintain or improve balance⁶.
However, a systematic review of the literature published after the year 2000, regarding PA levels of adults 60 years old + revealed that the percentage of older adults meeting the recommended PA levels ranged from 2.4 – 83% across studies. Older age groups were less likely than the reference group to be regularly active, and women were less likely than men to achieve regular physical activity, especially leisure time physical activity, when measured by both subjective and objective criteria⁷.
The reasons for low PA among older adults range from common myths or misconceptions, such as: exercise is no longer appropriate at this age, older people are frail and physically weak (and it would be dangerous to exercise), the human body doesn’t need as much physical activity as it ages, exercising is hazardous for older people because they may injure themselves, or only vigorous and sustained exercise is of any use. Other barriers to PA in older adults are: some older people may have a preference for sedentary activities, such as reading and socialising, the relatively high cost of some organized sports may exclude some people, many sports and activities tend to attract young adults, so older people may feel unwelcomed, the physical fitness marketplace has failed to include and attract older people⁵.
Low PA levels in people over the age of 50 years can experience a range of health problems including:

Reduced muscle mass, strength and physical endurance
Reduced coordination and balance
Reduced joint flexibility and mobility
Reduced cardiovascular and respiratory function
Reduced bone strength
Increased body fat levels
Increased blood pressure
Increased susceptibility to mood disorders, such as anxiety and depression
Increased risk of various diseases including cardiovascular disease and stroke⁵

Adequate nutrition and physical activity levels in the older adults population represent educational topics of the utmost importance for health & care workers, especially in the current socio-economic and epidemiological environments, characterized by inequities in access to services, social isolation and an increase in the percentages of population living under the poverty line.

Lesson 2: Assessment of poor nutrition and low PA in older adults and of health associated risks – frailty

Figure 1. Mini Nutritional Assessment (MNA) Tool

Nutritional Assessment

The Mini Nutritional Assessment (MNA) is a validated nutrition screening and assessment tool that can identify geriatric patients age 65 and above who are malnourished or at risk of malnutrition. The MNA® was developed nearly 20 years ago and is the most well validated nutrition screening tool for the elderly. Originally comprised of 18 questions, the current MNA® now consists of 6 questions and streamlines the screening process. The current MNA® retains the validity and accuracy of the original MNA® in identifying older adults who are malnourished or at risk of malnutrition. The revised MNA® Short Form makes the link to intervention easier and quicker and is now the preferred form of the MNA® for clinical use.

Physical Activity Scale for the Elderly (PASE) is a brief (5 minutes) and easily scored survey designed specifically to assess physical activity in epidemiological studies of persons age 65 years and older.

The PASE score combines information on leisure, household and occupational activity. The PASE assesses the types of activities typically chosen by older adults (walking, recreational activities, exercise, housework, yard work, and caring for others. It uses frequency, duration, and intensity level of activity over the previous week to assign a score, ranging from 0 to 793, with higher scores indicating greater physical activity⁸.

Occupational, household and leisure activities are investigated by PASE, over a one-week period. The questionnaire can be administered by mail or interview (telephone or in-person). The observed effect of mode of administration on physical activity estimates is of concern and authors recommend that the telephone version of PASE be the method of first choice, furthermore they suggest that the mail questionnaire be used in a modified form with additional respondent instructions in order to clarify the proper categorisation of activities, thus reducing reporting error in the mail version.

Physical Activity assessment

Physical Activity Scale for the Elderly (PASE)

Leisure Time Activity
1. Over the past 7 days, how often did you participate in sitting activities such as reading, watching TV, or doing handcrafts?
[0.] NEVER (go to question 2)
[1.] SELDOM (1-2 DAYS) (go to question 1.a and 1.b)
[2.] SOMETIMES (3-4 DAYS) (go to question 1.a and 1.b)
[3.] OFTEN (5-7 DAYS) (go to question 1.a and 1.b)
1.a What were these activities? (Open-ended question)
1.b On average, how many hours did you engage in these sitting activities?
[0.] Less than 1 hour
[1.] 1 but less than 2 hours
[2.] 2 - 4 hours
[3.] more than 4 hours
2. Over the past 7 days, how often did you take a walk outside your home or yard for any reason? For example, for fun or exercise, walking to work, walking the dog, etc
[0.] NEVER (go to question 3)
[1.] SELDOM (1-2 DAYS) (go to question 2.a)
[2.] SOMETIMES (3-4 DAYS) (go to question 2.a)
[3.] OFTEN (5-7 DAYS) (go to question 2.a)
2a. On average, how many hours per day did you spend walking?
[0.] Less than 1 hour
[1.] 1 but less than 2 hours
[2.] 2 - 4 hours
[3.] more than 4 hours
3. Over the past 7 days, how often did you engage in light sport or recreational activities such as bowling, golf with a cart, shuffleboard, fishing from a boat or pier or other similar activities?
[0.] NEVER (go to question 4)
[1.] SELDOM (1-2 DAYS) (go to question 3.a and 3.b)
[2.] SOMETIMES (3-4 DAYS) (go to question 3.a and 3.b)
[3.] OFTEN (5-7 DAYS) (go to question 3.a and 3.b)
3.a What were these activities? (open end question)
3.b On average, how many hours did you engage in these light sport or recreational activities?
[0.] Less than 1 hour
[1.] 1 but less than 2 hours
[2.] 2 - 4 hours
[3.] more than 4 hours
4. Over the past 7 days, how often did you engage in moderate sport and recreational activities such as doubles tennis, ballroom dancing, hunting, ice skating, golf without a cart, softball or other similar activities?
[0.] NEVER (go to question 5)
[1.] SELDOM (1-2 DAYS) (go to question 4.a and 4.b)
[2.] SOMETIMES (3-4 DAYS) (go to question 4.a and 4.b)
[3.] OFTEN (5-7 DAYS) (go to question 4.a and 4.b)
4.a What were these activities? (open end question)
4.b On average, how many hours did you engage in these moderate sport or recreational activities?
[0.] Less than 1 hour
[1.] 1 but less than 2 hours
[2.] 2 - 4 hours
[3.] more than 4 hours
5. Over the past 7 days, how often did you engage in strenuous sport and recreational activities such as jogging, swimming, cycling, singles tennis, aerobic dance, skiing (downhill or cross-country) or other similar activities?
[0.] NEVER (go to question 6)
[1.] SELDOM (1-2 DAYS) (go to question 5.a and 5.b)
[2.] SOMETIMES (3-4 DAYS) (go to question 5.a and 5.b)
[3.] OFTEN (5-7 DAYS) (go to question 5.a and 5.b)
5.a What were these activities? (open end question)
5.b On average, how many hours did you engage in these strenuous sport or recreational activities?
[0.] Less than 1 hour
[1.] 1 but less than 2 hours
[2.] 2 - 4 hours
[3.] more than 4 hours
6. Over the past 7 days, how often did you do any exercises specifically to increase muscle strength and endurance, such as lifting weights or push-ups, etc.?
[0.] NEVER (go to question 7)
[1.] SELDOM (1-2 DAYS) (go to question 6.a and 6.b)
[2.] SOMETIMES (3-4 DAYS) (go to question 6.a and 6.b)
[3.] OFTEN (5-7 DAYS) (go to question 6.a and 6.b)
6.a What were these activities? (open end question)
6.b On average, how many hours did you engage in these strenuous sport or recreational activities?
[0.] Less than 1 hour
[1.] 1 but less than 2 hours
[2.] 2 - 4 hours
[3.] more than 4 hours
Household Activity
7. During the past 7 days, have you done any light housework, such as dusting or washing dishes?
[1.] NO
[2.] YES
8. During the past 7 days, have you done any heavy housework or chores, such as vacuuming, scrubbing floors, washing windows, or carrying wood?
[1.] NO
[2.] YES
9. During the past 7 days, did you engage in any of the following activities? Please answer YES or NO for each item.
a. Home repairs like painting, wallpapering, electrical work, etc.
b. Lawn work or yard care, including snow or leaf removal, wood chopping, etc.
c. Outdoor gardening
d. Caring for another person, such as children, dependent spouse, or another adult
Work-related Activity
10. During the past 7 days, did you work for pay or as a volunteer?
[1.] NO
[2.] YES (go to questions 10.a and 10.b)
10a. How many hours per week did you work for pay and or as a volunteer? ____ hours
10b. Which of the following categories best describes the amount of physical activity required on your job and or volunteer work?
Mainly sitting with some slight arm movement (Examples: office worker, watchmaker, seated assembly line worker, bus driver, etc.)
Sitting or standing with some walking (Examples: cashier, general office worker, light tool and machinery worker)
Walking with some handling of materials generally weighing less than 50 pounds (Examples: mailman, waiter/waitress, construction worker, heavy tool and machinery worker)
Walking and heavy manual work often requiring handling of materials weighting over 50 pounds (Ex: lumberjack, ston mason, farm or general labourer)

Calculations

The PASE authors devised a set of item weights (Table 1) for the PASE questionnaire by using principal components analysis and regression techniques. Total PASE scores are computed by multiplying activity weights by activity frequencies.

Figure 2. Contribution of each questionnaire item to the overall PASE score is determined by the product of the sample mean and activity weight

Frailty risk assessment

The “Frailty Wheel” app

Figure 3. Frailty Wheel app panels

Frailty wheel is a quick assessment tool for social workers, clinicians, and other health care providers to assess patient frailty. The tool is intended to be used by social workers and other health care providers, in a variety of settings, to assess the frailty of their patients. The Frailty Wheel tool will identify patients who are at high risk of dependency on others for daily care, and can be used during phone visits or in-person visits. This "just in time" method will quickly select patients who may benefit from in-depth discharge planning, referrals to community resources, care conferencing with informal support, or frequent proactive follow-up by clinical staff.

The Frailty Wheel tool consists of four questions. Ask each question exactly as worded without probing or influencing the patient. Responses should be the patient's evaluation of their own abilities.
After answering all four questions, the app will tell you if the respondent is at an increased risk for frailty or not.
The Frailty Wheel tool is based on the validated methodology from the Health Status Questionnaire and is modeled after the printed Frailty Wheel that has been in use since 2002. The app does not save any patient or respondent information. It is intended to be used multiple times across different respondents. Only basic analytics and crashlytics data is collected for quality control and troubleshooting purposes.

FRAIL Project

FRAIL is a project to develop a smartwatch app that supports elderly individuals who are in a pre-frail or frail state. The app will monitor for falls, level of physical activity and interruption of routine activities, to help detect the onset of frailty and to prevent its consequences among the wearers.

Origins
Identification and assessment of frailty is essential for tailoring geriatric interventions. The currently available instruments for assessing frailty measure factors that require time-consuming screening processes, are difficult to use in primary care and also lack ecological validity. Smartwatch-based approaches seem particularly well suited for assessment of everyday living – especially when it comes to measuring core features of frailty, such as falls, low physical activity and interruptions in activities of daily living.

The FRAIL project aims to develop a smartwatch application designed to detect frailty among elderly individuals and to prevent the associated negative consequences. The app will be deployed on the market as a new key feature of LOLA, an existing health-monitoring app for the elderly marketed by the project partner Qolware. FRAIL’s frailty assessment feature, tested in multicentered international pilot studies of participants affected by different degrees of frailty, will monitor three key parameters:

Fall detection and prevention: A large pilot study with frail elderly individuals who have a high risk of falling will be used to make significant improvements in algorithms for the detection of the risk of falls.
Physical activity indicators for frailty: The frailty assessment will include other physical activity indicators outside of fall risk, and it will facilitate transferring detection of these indicators from a waist-worn device to a smartwatch device using the LOLA app.
Frailty detection in activities of daily living: TUM will provide specific parameters for assessing frailty in daily activities using the LOLA app.

The project’s design, low price, monitoring features and novelty character on the market provide a real added value.

Impact
The FRAIL solution will help seniors by directly support the prevention of frailty and its negative impact on their quality of life. It is expected that the app will engage thousands of European elderly citizens in protecting their health, increasing autonomy and bringing higher quality of life to them and their relatives. By helping keep seniors active and healthy for longer, it can provide benefits for caregivers, payers and healthcare systems⁹.

Sub-module / Lesson 3: Nutrition and PA interventions in older adults

Figure 4. My plate for older adults

The “MyPlate for Older Adults” (Figure 4) depicts a colourful plate with images to encourage older Americans to follow a healthy eating pattern bolstered by physical activity. The plate is consistent with the 2015 Dietary Guidelines for Americans.

KOKU (Keep On Keep Up)

Keep on Keep up is a simple, NHS-approved app that helps older adults improve strength, balance and optimise healthy ageing. Based on scientific research from clinical trials, Keep on Keep up provides tailored exercises and evidence based games which can be easily completed independently at home, by older adults. These simple exercises improve mobility and bone health which in turn, reduces the likelihood of falls. Keep on Keep up also improves health literacy increasing awareness of how to stay safe in the home.

After downloading “Keep on Keep up”, two simple steps will follow:

A fun onboarding (Figure 5) and app walkthrough (Figure 6) helps you understand how to use the app
Ability and confidence levels are selected to personalise the app to your needs

Once you have completed these steps you can begin some simple balance and strengthening exercises. Three daily exercises will be demonstrated for you, including a set of clear instructions from the app’s friendly guide, Wilf, plus all the safety advice you would need.

Overtime, daily exercises will become more challenging and you will enjoy the sense of satisfaction as you track your progress within the app.
Research to date includes multiple phases of testing and development with older adults and healthcare professionals. The strength and balance exercises are based on the evidence-based OTAGO/FaME exercise programmes specifically developed to improve function and prevent falls. You can feel assured that Keep on Keep up is safe to use as NHS Digital has assessed the platform and certified it as DCB0160 and DCB0129 compliant and of low risk to users.

Figure 5. “Keep on Keep up” app introductory panels

Figure 6. “Keep on Keep up” app walkthrough panels

Figures 5 above presents the KOKU app set up process, where information about the user is required in order to create a dedicated account.

Figure 6 illustrates the KOKU app walkthrough process, aiming at familiarizing the user with the app features.

Figure 7. “Keep On Keep Up” app action panels

Figure 7 above illustrates the KOKU app action panels, that include proposed daily exercises, the daily progress, a set of games and different types of exercises (outside the daily proposal).

QUIZ - Progress tracking / achievements

References:
1. https://pubmed.ncbi.nlm.nih.gov/31987100/
2. https://www.lifecareservices-seniorliving.com/blog/health-risks-of-poor-nutrition-for-seniors/
3.https://www.who.int/ageing/health-systems/icope/evidence-centre/ICOPE-evidence-profile-malnutrition.pdf?ua=1#:~:text=Undernutrition%20is%20common%20among%20older,%2Dincome%20countries%20(6).
4. https://www.betterhealth.vic.gov.au/health/healthyliving/Nutrition-needs-when-youre-over-65
5. https://www.betterhealth.vic.gov.au/health/healthyliving/physical-activity-for-seniors
6. https://www.who.int/dietphysicalactivity/physical-activity-recommendations-65years.pdf
https://www.aafp.org/afp/2010/0101/p55.html
7. https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-13-449.pdf
8. https://www.physio-pedia.com/Physical_Activity_Scale_for_the_Elderly_(PASE)
9. https://eithealth.eu/project/frail/#:~:text=FRAIL%20is%20a%20project%20to,its%20consequences%20among%20the%20wearers
https://www.betterhealth.vic.gov.au/health/healthyliving/Nutrition-needs-when-youre-over-65