As the global population continues to aging, atrial fibrillation (AF) has become one of the biggest medical and social problems worldwide[1].This increasing burden is a challenge for global health systems. AF is the most common arrhythmia in the general population[2]. However,available epidemiological data suggest that AF has its highest prevalence in the elderly[3]. With increasing age, the number of cases of AF also increases dramatically: It has 0.1% of the population under the age of 55, 3.3% over the age of 60, and 10% over the age of 80[4]. An epidemiologic survey in China showed that the prevalence of AF increases with age, with prevalence rates of 5.4% in men and 4.9% in women over the age of 75[5]. The latest guidelines state that improved diagnosis of new cases, the influence of various cardiovascular risk factors, and an aging society have all increased the incidence of AF[6]. Because AF can lead to cerebral infarction and heart failure, elderly patients with AF have a significantly increased risk of stroke death, cardiovascular death, and all-cause mortality compared with non-AF[7]. Therefore, the life safety of elderly patients with AF is seriously threatened.
Moreover, frailty has been recognized as an important predictor for cardiovascular disease in elderly patients with AF. Frailty has clinically significant physiological changes that can manifest as a decrease in muscle mass and strength, a decrease in endurance, and a decline in the capacity of multiple organ systems[7, 8]. When a stressful event (such as an acute illness) occurs, the frailty population is prone to rapid functional deterioration, resulting in a significantly increased risk of falls, incapacitation, cardiovascular events, and death[7]. Given the gradual ageing of the population, frailty has rapidly become an urgent public health problem priority, requiring specific interventions and strategies. In an Italian study, 88.6% of patients with AF at a mean age of 80 years were found to be combined with frailty[9], and it has been shown that frailty can contribute to further exacerbation of AF [10]. It is estimated that by 2050, AF will affect over 9 million elderly people aged 60 and above in China[11].Therefore, the management of elderly patients with AF and frailty is crucial.
Studies have shown that moderate intensity physical activity has significant positive effects on both AF and frailty in older adults. A Korean study conducted a retrospective analysis of 66,692 patients newly diagnosed with AF between 2010 and 2016[12]. The study collected patients' exercise in the two years before and after diagnosis. At follow-up, they categorized the study participants as non-exercisers (30.5%), new exercisers (17.8%), quitters (17.4%), and keepers (34.2%)[12]. The results showed that patients who exercised at any time before or after the diagnosis of AF had a significantly lower risk of death, new exercisers and exercise maintainers had a significantly lower risk of heart failure compared with persistent non-exercisers, and the benefits of moderate exercise as an intervention for frail patients have become clearer[12]. More and more evidence shows that exercise is one of the main strategies to reduce frailty-related physical damage in the elderly, and the primary mechanism at play may be that exercise has the ability to diminish age-related oxidative damage and chronic inflammation, while also enhancing mitochondrial function and actin distribution[13]. One study suggests that exercise training for elderly patients with AF can prevent and delay frailty[14].
The latest European Society of Cardiology (ESC) guidelines for the diagnosis and management of AF also state that "patients should be encouraged to engage in moderate-intensity exercise and to remain physically active to prevent the onset or recurrence of AF."[15]. In addition, the ESC, in its latest guidelines on exercise cardiology and exercise for patients with cardiovascular disease, points to the important role of physical activity for people with risk factors for cardiovascular disease[16]. At present, there are no specific physical activity strategies for the elderly patients with AF and frailty group. Therefore, we attempted to develop a physical activity intervention based on the behavioral change wheel theory to meet the physical activity needs of elderly AF-combined frailty patients, as well as to improve their quality of life and slow disease progression.
Previous studies have shown that interventions based on the Behavior Change Wheel(BCW) theory are effective in promoting behavioral change[17–21]. The BCW is a model that integrates 19 behavior change frameworks[22].It has a three-layer wheel structure(see Figure.1), of which the core is the COM-B model with three basic conditions, including: ability, opportunity, and motivation[22]. It has a middle layer of nine intervention functions, including: education, persuasion, motivation, coercion, training, restriction, environmental remodelling, modelling, and empowerment, through which our interventions can change behavior[22]. On the outermost layer are seven policy categories that contribute to the implementation of the intervention function[22]. In addition, behavior change techniques༈BCT༉ are interrelated with BCW and can help design interventions[22, 23].The theoretical domain framework(TDF) consists of 14 domains that can extend the COM-B model to help promote behavior change[24].However, no known study in China has attempted to use the BCW framework to develop physical activity behaviors in elderly patients with AF combined with frailty.
According to the BCW guidelines[22, 25], using BCW theory to construct a behavior change intervention program requires three phases for a total of eight steps(see Figure.2). Therefore, we developed physical activity interventions through these three stages and eight steps to support physical activity in older adults with AF and frailty. We hope to provide a reference for healthcare professionals when formulating physical activity for elderly patients with AF and frailty, and ultimately improve quality of life and clinical health outcomes in older adults with AF and frailty. Finally, we hope that the interventions identified in this study will provide researchers with reference value in area of behavior change.
The Behavior Change Wheel (used with permission from authors)