Effect of 12-month supervised, home-based physical exercise on functioning among persons with signs of frailty - Randomized Controlled Trial

Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Falls are the most common cause of injury-related morbidity and mortality in older adults.

Objective

To systematically review evidence on the effectiveness and harms of fall prevention interventions in community-dwelling older adults.

Data Sources

MEDLINE, Cumulative Index for Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Clinical Trials for relevant English-language literature published between January 1, 2016, and May 8, 2023, with ongoing surveillance through March 22, 2024.

Study Selection

Randomized clinical trials of interventions to prevent falls in community-dwelling adults 65 years or older.

Data Extraction and Synthesis

Critical appraisal and data abstraction by 2 independent reviewers. Random-effects meta-analyses with Knapp-Hartung adjustment.

Main Outcomes and Measures

Falls, injurious falls, fall-related fractures, hospitalizations or emergency department visits, people with 1 or more falls, people with injurious falls, people with fall-related fractures, and harms.

Results

Eighty-three fair- to good-quality randomized clinical trials (n = 48 839) examined the effectiveness of 6 fall prevention interventions in older adults. This article focuses on the 2 most studied intervention types: multifactorial (28 studies; n = 27 784) and exercise (37 studies; n = 16 117) interventions. Multifactorial interventions were associated with a statistically significant reduction in falls (incidence rate ratio [IRR], 0.84 [95% CI, 0.74-0.95]) but not a statistically significant reduction in individual risk of 1 or more falls (relative risk [RR], 0.96 [95% CI, 0.91-1.02]), injurious falls (IRR, 0.92 [95% CI, 0.84-1.01]), fall-related fractures (IRR, 1.01 [95% CI, 0.81-1.26]), individual risk of injurious falls (RR, 0.92 [95% CI, 0.83-1.02]), or individual risk of fall-related fractures (RR, 0.86 [95% CI, 0.60-1.24]). Exercise interventions were associated with statistically significant reductions in falls (IRR, 0.85 [95% CI, 0.75-0.96]), individual risk of 1 or more falls (RR, 0.92 [95% CI, 0.87-0.98]), and injurious falls (IRR, 0.84 [95% CI, 0.74-0.95]) but not individual risk of injurious falls (RR, 0.90 [95% CI, 0.79-1.02]). Harms associated with multifactorial and exercise interventions were not well reported and were generally rare, minor musculoskeletal symptoms associated with exercise.

Conclusions and Relevance

Multifactorial and exercise interventions were associated with reduced falls in multiple good-quality trials. Exercise demonstrated the most consistent statistically significant benefit across multiple fall-related outcomes.

Effectiveness of a mHealth platform-based lifestyle integrated multicomponent exercise (PF-Life) program to reverse pre-frailty in community-dwelling older adults: a randomized controlled trial study protocol

Background

Pre-frailty represents an ideal window of opportunity to potentially prevent frailty and disability. Early and effective interventions to delay or reverse pre-frailty are public health imperative. The present trial aims to evaluate the effectiveness and underlying mechanisms of mobile health (mHealth) platform-supported lifestyle-integrated multicomponent exercise (PF-Life) to reverse pre-frailty in community-dwelling older adults.

Methods

This is an open-label, prospective, two-arm parallel randomized controlled trial with allocation concealment and outcome assessment blinding. We aim to recruit 140 pre-frail community-dwelling older adults who will be randomized into two groups. The control group will receive a health education program, while the intervention group will receive PF-Life training as planned for 1 year. The proportion of pre-frailty, functional performance (muscular strength, aerobic capacity, flexibility, and balance), body composition, and physical activity will be measured at pre-intervention, post-intervention, and 12-month follow-up. Inflammatory biomarkers will also be collected to explore the underlying mechanisms.

Discussion

This is the first study to evaluate the effects of a novel digital lifestyle-integrated multicomponent exercise for pre-frail older people. The results of this trial will provide much-needed information on the short-and long-term effects of PF-Life based on functional performance and body composition. Meanwhile, inflammatory biomarkers and physical activity levels will be used to elucidate the underlying mechanisms of PF-Life. The findings from this trial will provide evidence for the effectiveness of lifestyle multicomponent exercise intervention supported by the mHealth platform that may reverse or even halt the onset of frailty.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=176477, identifier ChiCTR2200063431.

Rehabilitation in primary care for an ageing population: a secondary analysis from a scoping review of rehabilitation delivery models

BACKGROUND

The world population is ageing rapidly. Rehabilitation is one of the most effective health strategies for improving the health and functioning of older persons. An understanding of the current provision of rehabilitation services in primary care (PC) is needed to optimise access to rehabilitation for an ageing population. The objectives of this scoping review are a) to describe how rehabilitation services are currently offered in PC to older persons, and b) to explore age-related differences in the type of rehabilitation services provided.

METHODS

We conducted a secondary analysis of a scoping review examining rehabilitation models for older persons, with a focus on PC. Medline and Embase (2015-2022) were searched to identify studies published in English on rehabilitation services for people aged 50 + . Two authors independently screened records and extracted data using the World Health Organization (WHO)'s operational framework, the Primary Health Care Systems (PRIMASYS) approach and the WHO paper on rehabilitation in PC. Data synthesis included quantitative and qualitative analysis.

RESULTS

We synthesised data from 96 studies, 88.6% conducted in high-income countries (HICs), with 31,956 participants and identified five models for delivering rehabilitation to older persons in PC: community, home, telerehabilitation, outpatient and eldercare. Nurses, physiotherapists, and occupational therapists were the most common providers, with task-shifting reported in 15.6% of studies. The most common interventions were assessment of functioning, rehabilitation coordination, therapeutic exercise, psychological interventions, and self-management education. Environmental adaptations and assistive technology were rarely reported.

CONCLUSIONS

We described how rehabilitation services are currently provided in PC and explored age-related differences in the type of rehabilitation services received. PC can play a key role in assessing functioning and coordinating the rehabilitation process and is also well-placed to deliver rehabilitation interventions. By understanding models of rehabilitation service delivery in PC, stakeholders can work towards developing more comprehensive and accessible services that meet the diverse needs of an ageing population. Our findings, which highlight the role of rehabilitation in healthy ageing, are a valuable resource for informing policy, practice and future research in the context of the United Nations Decade of Healthy Ageing, the Rehab2030 initiative and the recently adopted WHA resolution on strengthening rehabilitation in health systems, but the conclusions can only be applied to HICs and more studies are needed that reflect the reality in low- and middle-income countries.

Effectiveness of aerobic exercise in the prevention and treatment of postpartum depression: Meta-analysis and network meta-analysis

BACKGROUND

Aerobic exercise is widely recognized for improving mental health and reducing negative emotions, including anxiety. However, research on its role in preventing and treating postpartum depression (PPD) has yielded inconsistent results. Some studies show positive effects on PPD symptoms, while others find limited impact, suggesting various factors at play, such as exercise type, intensity, and individual differences. To address this gap, our study aims to comprehensively gather evidence on the preventive and therapeutic effects of aerobic exercise for PPD. We'll focus on differences in exercise program design and implementation, exploring how these factors impact intervention outcomes. By identifying effective exercise approaches, we aim to provide more comprehensive exercise prescription recommendations for this vulnerable population.

METHODS

We conducted a quantitative systematic review of the study in 5 representative databases for the effect of aerobic exercise on PPD. Meta-analysis and network meta-analysis were performed with Review-Manager.5.4 and Stata.16.0 software, respectively. This study has been registered on the official Prospero website, and the registration code is CRD42023398221.

RESULTS

Twenty-six studies with 2,867 participants were eventually included and the efficacy of aerobic exercise in preventing and treating postpartum depression is significant compared to standard care. (MD = -1.90; 95%CL: -2.58 to -1.21; I2 = 86%). Subgroup analysis suggests that the intervention objective (prevention vs. treatment) of exercise could potentially be a source of heterogeneity in this study, as the "Test for subgroup difference" revealed the presence of significant distinctions (p = 0.02<0.05). The "Test for subgroup difference" yielded non-significant results for both the supervised vs. unsupervised subgroup comparison (p = 0.55 > 0.05) and the individual vs. team subgroup comparison (p = 0.78 > 0.05). Nonetheless, when assessing their effect sizes [Subtotal (95%CL)], the supervised exercise group [-1.66 (-2.48, -0.85)] exhibited a slightly better performance than the unsupervised exercise group [-1.37 (-1.86, -0.88)], while the team exercise group [-1.43 (-1.94, -0.93)] slightly outperformed the individual exercise group [-1.28 (-2.23, -0.33)]. Network meta-analysis indicated that moderate intensity (35~45 min) group demonstrated a more pronounced intervention effect compared to low intensity (50~60 min) group [-2.63 (-4.05, -1.21)] and high intensity (20~30 min) group [-2.96 (-4.51, -1.41)], while the 3~4 times/week group had a more significant intervention effect compared to 1~2 times/week groups [-2.91 (-3.99, -1.83)] and 5~6 times/week groups [-3.28 (-4.75, -1.81)]. No significant differences were observed in pairwise comparisons of intervention effects among the five common types of aerobic exercises. (95%CL including 0). The Surface Under the Cumulative Ranking curve (SUCRA) results align with the findings mentioned above and will not be reiterated here.

CONCLUSION

The efficacy of aerobic exercise in preventing and treating postpartum depression is significant compared to standard care, with a greater emphasis on prevention. The optimal prescribed exercise volume for intervention comprises a frequency of 3~4 exercise sessions per week, moderate intensity (35~45 minutes). Currently, several uncharted internal factors influence the optimal intervention effect of aerobic exercise, such as the potential enhancement brought by team-based and supervised exercise. Given the absence of significant differences in certain results and the limitations of the study, it is essential to exercise caution when interpreting the outcomes. Further research is needed in the future to provide a more comprehensive understanding.

Development of a Frailty Ladder Using Rasch Analysis: If the Shoe Fits

Background

The current measurement approach to frailty is to create an index of frailty status, rather than measure it. The purpose of this study is to test the extent to which a set of items identified within the frailty concept fit a hierarchical linear model (e.g., Rasch model) and form a true measure reflective of the frailty construct.

Methods

A sample was assembled from three sources: community organization for at-risk seniors (n=141); colorectal surgery group assessed post-surgery (n=47); and hip fracture assessed post-rehabilitation (n=46). The 234 individuals (age 57 to 97) contributed 348 measurements. The frailty construct was defined according to the named domains within commonly used frailty indices, and items drawn to reflect the frailty came from self-report measures. Performance tests were tested for the extent to which they fit the Rasch model.

Results

Of the 68 items, 29 fit the Rasch model: 19 self-report items on physical function and 10 performance tests, including one for cognition; patient reports of pain, fatigue, mood, and health did not fit; nor did body mass index (BMI) nor any item representing participation.

Conclusion

Items that are typically identified as reflecting the frailty concept fit the Rasch model. The Frailty Ladder would be an efficient and statistically robust way of combining results of different tests into one outcome measure. It would also be a way of identifying which outcomes to target in a personalized intervention. The rungs of the ladder, the hierarchy, could be used to guide treatment goals.

Exercise based reduction of falls in communitydwelling older adults: a network meta-analysis

BACKGROUND

Traditional meta-analyses with pairwise direct comparison revealed that a variety of exercise-based training interventions can prevent falls in community-dwelling older adults. This network meta-analysis adds value by comparing and ranking different exercise training strategies based on their effects on fall risk reductions determined by analysis of direct and indirect comparisons.

METHODS

The studies included in this network meta-analysis were identified through a comprehensive search in five biomedical databases (PubMed, SportDiscus, CINAHL, Web of Science and EMBASE). We included (randomized) controlled trials (RCTs) that compared the occurance of fall events in older adults who received different interventional treatments.

RESULTS

Seventy six comparisons from 66 RCTs with 47.420 (61% male / 39% female) participants aged 77 ± 4 (68 - 88) years were included in this network meta-analysis. The network model revealed low heterogeneity (I² = 28.0, 95%CI 1.0 to 47.7%) and inconsistency (Q between designs = 15.1, p = 0.37). Postural control training was found to be most effective in preventing falls (Postural Control Training: (home): Risk Ratio (RR) = 0.66, 95%-CI [0.49; 0.88], P-score = 0.97;Postural Control Training: RR = 0.82, 95%-CI [0.75; 0.91], P-score = 0.82). Combined and multifactorial interventions also display a robust but smaller effect (RR = 0.88-0.93, P-score = 0.65-0.47).

CONCLUSION

Physical activity that includes balance training presents itself to be the most effective. Multifactorial approaches are well investigated but could be slightly less effective than isolated postural control training.

Role of Endothelial Progenitor Cells in Frailty

Frailty is a clinical condition closely related to aging which is characterized by a multidimensional decline in biological reserves, a failure of physiological mechanisms and vulnerability to minor stressors. Chronic inflammation, the impairment of endothelial function, age-related endocrine system modifications and immunosenescence are important mechanisms in the pathophysiology of frailty. Endothelial progenitor cells (EPCs) are considered important contributors of the endothelium homeostasis and turn-over. In the elderly, EPCs are impaired in terms of function, number and survival. In addition, the modification of EPCs' level and function has been widely demonstrated in atherosclerosis, hypertension and diabetes mellitus, which are the most common age-related diseases. The purpose of this review is to illustrate the role of EPCs in frailty. Initially, we describe the endothelial dysfunction in frailty, the response of EPCs to the endothelial dysfunction associated with frailty and, finally, interventions which may restore the EPCs expression and function in frail people.

Effect of the Active Aging-in-Place-Rehabilitation Nursing Program: A Randomized Controlled Trial

(1) Background: It is of great importance to promote functional capacity and positive lifestyles, since they contribute to preventing the progression of frailty among the older adults. The aim of this study was to evaluate the effect of active aging-in-place−rehabilitation nursing program (AAP-RNP) on the functional capacity and lifestyles of frail older adults. (2) Methods: This was a single-blinded, two-group, randomized, controlled trial of 30 frail older people enrolled at a Health-care unit in Portugal between 2021 and 2022. The duration of the program was 12 weeks, and the sessions took place at the participants’ homes. We used as instruments the Tilburg Frailty Indicator; Fried frailty phenotype; Senior Fitness Test battery; Barthel Index; Lawton Index; handgrip strength measurement; Tinetti Index; Individual lifestyle profile; and Borg’s perception of effort. (3) Results: Post-program, there was an improvement in multidimensional and physical frailty, functional capacity, balance, and perceived exertion (p < 0.05) in the experimental group. Among the older adults’ lifestyles, we observed significant improvements in physical activity habits, relational behavior, and stress management. (4) Conclusions: Rehabilitation nurses have a relevant role, and the AAP-RNP seems to be effective in improving functional capacity and lifestyles in frail older adults.

Effects of Adding an Online Exercise Program on Physical Function in Individuals Hospitalized by COVID-19: A Randomized Controlled Trial

The worldwide pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has impacted all healthcare systems. One potential sequela experienced by hospitalized coronavirus disease 2019 (COVID-19) survivors includes muscle weakness with a reduction in strength and, consequently, a possible increase in frailty. The aim of this clinical trial was to evaluate the efficacy of adding an online therapeutic exercise program for 8 weeks to the medical prescriptions on functional variables in patients hospitalized due to COVID-19. A randomized controlled trial including 70 previously hospitalized COVID-19 survivors was conducted. Patients were randomly allocated to an experimental (n = 35) or control (n = 35) group. Both groups received regular prescriptions provided by their medical doctors. The experimental group also received a live online therapeutic exercise program for 8 weeks (3 sessions/week). Handgrip strength, gait speed, lower-extremity strength, balance, and frailty were assessed at baseline, at the end of the program, and one month after the end of the intervention. The repeated measures analysis of variance revealed significant Group*Time interactions for all the outcomes: (handgrip dominant: F = 17.395, p < 0.001, η² = 0.24; handgrip non-dominant: F = 33.197, p < 0.001, η² = 0.33; 4 m walk test (4WT): F = 13.039, p = 0.001, η² = 0.16; short physical performance battery (SPPB): F = 26.421, p < 0.001, η² = 0.28; the five chair-raise test (5CRT): F = 5.628, p = 0.004, η² = 0.08; FRAIL scale: F = 11.249, p = 0.001, η² = 0.14): patients in the experimental group experienced greater improvements in all outcomes than those assigned to the control group. This study revealed that the addition of an online exercise program for 8 weeks obtained greater improvements in handgrip strength, gait speed, lower-extremity strength, balance, and frailty in a sample of previously hospitalized COVID-19 survivors than application of just usual medical prescription.

Changes in the Severity of Frailty Among Older Adults After 12 Months of Supervised Home-Based Physical Exercise: A Randomized Clinical Trial

OBJECTIVE

To investigate the effects of 12 months of physiotherapist-supervised, home-based physical exercise on the severity of frailty and on the prevalence of the 5 frailty phenotype criteria, using secondary analyses.

DESIGN

Randomized clinical trial, with 1:1 allocation into 12-month home-based physical exercise, or usual care. The multicomponent exercise sessions (60 minutes) were supervised by the physiotherapist and included strength, balance, functional, and flexibility exercises twice a week at participants' homes.

SETTING AND PARTICIPANTS

Home-dwelling older adults aged ≥65 years who were frail (meeting 3-5 criteria) or prefrail (1-2 criteria) according to frailty phenotype criteria.

METHODS

The severity of frailty (nonfrail, prefrail, or frail) was assessed using frailty phenotype criteria, and the prevalence of each frailty criterion (weight loss, low physical activity, exhaustion, weakness, and slowness) were assessed at baseline and at 12 months.

RESULTS

Two hundred ninety-nine persons were included in the analyses, of whom 184 were prefrail and 115 were frail at baseline. Their mean age was 82.5 (SD 6.3) years, and 75% were women. There was a significant difference between the exercise and usual care groups' transitions to different frailty states from baseline to 12 months among those who at baseline were prefrail (P = .032) and frail (P = .009). At 12 months, the mean number of frailty criteria had decreased in the exercise group (-0.27, 95% CI -0.47, -0.08) and remained unchanged in the usual care group (0.01, 95% CI -0.16, 0.18; P = .042). The prevalence of the exhaustion (P = .009) and the low physical activity (P < .001) criteria were lower at 12 months in the exercise group than in the usual care group.

CONCLUSIONS AND IMPLICATIONS

The severity of frailty can be reduced through 12-month supervised home-based exercise training. Exercise should be included in the care of older adults with signs of frailty.

A theory-driven exercise intervention among community-dwelling (pre)frail older adults: Protocol for a stepped-wedge cluster-randomized trial

AIM

This study is aimed to evaluate the effectiveness of a theory-driven exercise intervention for Chinese community-dwelling (pre)frail older adults, and to clarify the underlying mechanisms of the exercise intervention in this population.

DESIGN

A stepped-wedge cluster-randomized trial.

METHODS

A stepped-wedge cluster-randomized trial will be conducted among (pre)frail older adults at six communities in a county of central China. A 12-week multicomponent exercise intervention based on the integration of the Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB) will be implemented to all participants during the study period. The primary outcomes are frailty, muscle mass, muscle strength and physical performance. Secondary outcomes include beliefs in exercise, exercise behaviours and other physical, mental and social functioning. Assessments will be conducted at baseline and at week 12, 24 and 36. A multilevel regression model will be used to evaluate the effectiveness of exercise interventions. A multilevel mediation model will be used to clarify the underlying mechanisms of this exercise intervention.

DISCUSSION

This study is expected to provide an effective and practical mode for exercise interventions among Chinese community-dwelling (pre)frail older adults, and contribute to the existing evidence in this field.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100041981.

Effects of Remotely Supervised Physical Activity on Health Profile in Frail Older Adults: A Randomized Controlled Trial Protocol

Background

Frailty is considered a major public health challenge of the 21st century, characterized by the decline of multiform body functions. Physical activity may be the most effective intervention to delay frailty. This study aims to verify the effect of remotely supervised physical activity on health profile in community-dwelling frail older adults.

Design

This is a multicenter, three-blind, two-arm, and cohort randomized controlled study.

Methods

The intelligent exercise rehabilitation management system (IERMS) is an integrated digital platform that involves evaluation, guidance, monitoring, and feedback. A total of 120 participants aged ≥ 65 years and diagnosed as frailty on the FRAIL scale will be recruited and randomly divided into two groups. Group 1 will receive a 12-week IERMS-based intervention, and Group 2 will receive the usual care. Data will be collected at baseline, 12 and 24 weeks. The primary outcome is the physical function, and secondary outcomes include gait parameters, psychology, and cognition measurements. Analyses will be performed using DSS statistics, version 25. P < 0.05 will be considered statistically significant.

Conclusion

We believe that intervention plays a positive role in delaying the frailty. If our program is effective, we will provide a viable means to promote healthy aging in primary healthcare.

Trial registration number

ChiCTR2100052286; Pre-results.