The Effect of Teleconsultation, on the Reversibility of Frailty in Geriatric Patients Post Hospitalization (TeleFrailty)

The Effect of Structured Teleconsultation, as Part of Discharge Planning, on the Reversibility of Frailty in Geriatric Patients Post Hospitalization: a Clinical Trial Based on Clinical Scores and Biological Markers

The goal of this clinical trial is to learn if a structured tele-consultation program, delivered 3 times over 12 weeks, can improve (reverse) frailty in geriatric patients recently discharged from the hospital. The main questions it aims to answer are:

• Does structured tele-consultation covering physical exercise, nutrition, and home care education change health behavior in older adults after hospital discharge?
• Does this change in health behavior lead to improvement in frailty, as measured by Clinical Frailty Scale (CFS) score?
• Does this change in health behavior lead to improvement in frailty, as measured by decreased interleukin-6 (IL-6) and myostatin levels and increased albumin levels?
• Does this change in health behavior lead to improvement in frailty, as measured by increased hand grip strength?

Researchers will compare participants receiving structured tele-consultation (delivered 3 times over 12 weeks) to participants receiving usual care to see if tele-consultation leads to greater improvement in health behavior and frailty status.

Participants will:

• Undergo baseline assessment of CFS score, hand grip strength, and blood sampling for IL-6, albumin, and myostatin shortly after hospital discharge
• Be randomly assigned to receive either structured tele-consultation (3 sessions over 12 weeks, covering physical exercise, nutrition, and home care education) or usual care
• Undergo repeat assessment of health behavior, CFS score, hand grip strength, and the same blood markers at the end of the 12-week period

Study Overview

• Status: Not yet recruiting
• Conditions: Frail Elderly; Prefrail Elderly
• Intervention / Treatment: Behavioral: structured teleconsultation and face to face consultation; Behavioral: face to face concultation

Detailed Description

Frailty is common among older adults following hospitalization and is associated with increased risk of readmission, functional decline, and mortality. Telemedicine has been proposed to support frailty management, but prior studies have used varied formats and shown inconsistent results, and no prior study has evaluated structured tele-consultation targeting physical exercise, nutrition, and home care education as a means of reversing frailty in older adults after hospital discharge, using both a validated frailty score and biological markers as outcomes.

This study is a randomized controlled trial conducted among older adults admitted to the acute geriatric ward who are deemed fit for discharge. Eligible patients are enrolled after providing informed consent, and baseline data (frailty scores, biological markers, hand grip strength) are collected prior to discharge. Participants are randomly allocated to an intervention group or a control group. Both groups receive standard discharge planning and follow-up at the geriatric outpatient clinic over a 12-week period after discharge. In addition to standard follow-up, participants in the intervention group receive structured tele-consultation sessions addressing physical exercise, nutrition, and home care education, delivered by a trained physician, dietitian, and physiotherapist. Outcome assessments are performed at baseline and at the end of the follow-up period by an assessor unaware of participants' group allocation.

Participants who are readmitted to hospital during the study period are withdrawn from the study. All collected data are kept confidential and used only for research purposes. Data from participants who withdraw or are lost to follow-up are retained and analyzed using an intention-to-treat approach.

• Study Type: Interventional
• Enrollment (Estimated): 116
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Arya Govinda Roosheroe, MD; Phone Number: +62 812-9430-3863; Email: argov0504@gmail.com

Study Locations

• Indonesia
  • Central Jakarta
    • Jakarta, Central Jakarta, Indonesia, 10430
      • Cipto Mangumkusumo Hospital
      • Contact: Arya Govinda Roosheroe, MD; Phone Number: +62 812-9430-3863; Email: argov0504@gmail.com
      • Principal Investigator: Arya Govinda Roosheroe, MD
      • Sub-Investigator: Siti Setiati, Prof, MD, PhD
      • Sub-Investigator: Kuntjoro Harimurti, MD, PhD
      • Sub-Investigator: Edy Rizal Wachyudi, MD< PhD
      • Sub-Investigator: IGP Suka Aryana, MD< PhD
      • Sub-Investigator: Nurul Ratna Mutu Manikam, MD, PhD
      • Sub-Investigator: Melinda Harini, MD< PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 60 years or older
• Approved for hospital discharge
• Diagnosed with pre-frailty or frailty
• Access to a mobile phone, tablet, or laptop

Exclusion Criteria:

• Unwilling to participate in the study
• Depression, as indicated by a Geriatric Depression Scale (GDS) score ≥10, assessed at the time of discharge
• Moderate to severe cognitive impairment, as indicated by a Montreal Cognitive Assessment-Indonesian version (MoCA-INA) score <26, assessed at the time of discharge
• Severe frailty, as indicated by a Clinical Frailty Scale (CFS) score >8
• Liver cirrhosis
• Chronic kidney disease stage 4 or higher
• Stage 4 malignancy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Teleconsultation group; Participants received standard discharge planning and standard face-to-face outpatient visits (consultation) at weeks 1, 5, 9, 13 post-discharge, plus structured teleconsultation (via Zoom, up to 60 minutes) conducted by a trained general practitioner, dietitian, and physiotherapist at weeks 3, 7, 11, post-discharge.	Behavioral: structured teleconsultation and face to face consultation; A structured teleconsultation delivered via videoconference (Zoom), up to 60 minutes per session, provided by a trained general practitioner, dietitian, and physiotherapist. Sessions were conducted with the patient and a consistent family member/caregiver at weeks 3, 7, 11 post-discharge, in addition to standard discharge planning and routine face-to-face outpatient visits at weeks 1, 5, 9, 13.
Active Comparator: face to face consultation group; Participants received standard discharge planning and standard face-to-face outpatient visits (consultation) only, at weeks 1, 5, 9, 13 post-discharge, without additional teleconsultation.	Behavioral: face to face concultation; Routine face-to-face outpatient visits to the geriatric clinic at weeks 1, 5, 9, 13, post-discharge, without additional telehealth consultation.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Clinical Frailty Scale (CFS) Score	Frailty reversibility assessed as the change in Clinical Frailty Scale (CFS) score from baseline (pre-intervention, at hospital discharge) to post-intervention, following structured telehealth consultation based on physical exercise, nutrition, and home care education aimed at health behavior change.	Baseline (at hospital discharge) and Week 13 post-discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Health Behavior	Change in health-related behavior (physical exercise, nutrition, and home care practices) following structured teleconsultation, assessed using validated behavioral questionaire	Baseline and Week 13 post-discharge
Change in Serum Albumin Level	Change in serum albumin level as a nutritional biomarker associated with frailty reversibility, following structured telehealth consultation.	Baseline and Week 13 post-discharge
Change in Serum Myostatin Level	Change in serum myostatin level as a biomarker of muscle wasting associated with frailty reversibility, following structured telehealth consultation.	Baseline and Week 13 post-discharge
Change in Hand Grip Strength	Change in hand grip strength, measured using a dynamometer, as an indicator of physical frailty component, following structured telehealth consultation.	Baseline and Week 13 post-discharge
Change in IL-6	Change in IL-6 following structured telehealth consultation.	Baseline and Week 13 post-discharge

Collaborators and Investigators

• Sponsor: Indonesia University

Study record dates

Study Major Dates

• Study Start (Estimated): August 3, 2026
• Primary Completion (Estimated): June 30, 2027
• Study Completion (Estimated): August 31, 2027

Study Registration Dates

• First Submitted: July 14, 2026
• First Submitted That Met QC Criteria: July 14, 2026
• First Posted (Actual): July 17, 2026

Study Record Updates

• Last Update Posted (Actual): July 17, 2026
• Last Update Submitted That Met QC Criteria: July 14, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: frailty; elderly; teleconsultation; prefrail; reversibility frailty
• Additional Relevant MeSH Terms: Pathologic Processes; Pathological Conditions, Signs and Symptoms; Frailty
• Other Study ID Numbers: 26-05-0746

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No