The effects of multidimensional exercise on functional decline, urinary incontinence, and fear of falling in community-dwelling elderly women with multiple symptoms of geriatric syndrome: a randomized controlled and 6-month follow-up trial

Efficacy of a Therapeutic Pelvic Yoga Program Versus a Physical Conditioning Program on Urinary Incontinence in Women : A Randomized Trial

BACKGROUND

Pelvic floor yoga has been recommended as a complementary treatment strategy for urinary incontinence (UI) in women, but evidence of its efficacy is lacking.

OBJECTIVE

To evaluate the effects of a therapeutic pelvic floor yoga program versus a nonspecific physical conditioning program on UI in women.

DESIGN

Randomized trial. (ClinicalTrials.gov: NCT03672461).

SETTING

Three study sites in California, United States.

PARTICIPANTS

Ambulatory women aged 45 years or older reporting daily urgency-, stress-, or mixed-type UI.

INTERVENTION

Twelve-week program of twice-weekly group instruction and once-weekly self-directed practice of pelvic floor-specific Hatha yoga techniques (pelvic yoga) versus equivalent-time instruction and practice of general skeletal muscle stretching and strengthening exercises (physical conditioning).

MEASUREMENTS

Total and type-specific UI frequency assessed by 3-day voiding diaries.

RESULTS

Among the 240 randomly assigned women (age range, 45 to 90 years), mean baseline UI frequency was 3.4 episodes per day (SD, 2.2), including 1.9 urgency-type episodes per day (SD, 1.9) and 1.4 stress-type episodes per day (SD, 1.7). Over a 12-week time period, total UI frequency (primary outcome) decreased by an average of 2.3 episodes per day with pelvic yoga and 1.9 episodes per day with physical conditioning (between-group difference of -0.3 episodes per day [95% CI, -0.7 to 0.0]). Urgency-type UI frequency decreased by 1.2 episodes per day in the pelvic yoga group and 1.0 episode per day in the physical conditioning group (between-group difference of -0.3 episodes per day [CI, -0.5 to 0.0]). Reductions in stress-type UI frequency did not differ between groups (-0.1 episodes per day [CI, -0.3 to 0.3]).

LIMITATION

No comparison to no treatment or other clinical UI treatments; conversion to videoconference-based intervention instruction during the COVID-19 pandemic.

CONCLUSION

A 12-week pelvic yoga program was not superior to a general muscle stretching and strengthening program in reducing clinically important UI in midlife and older women with daily UI.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Does combining two evidence-based exercise programs in elderly people with incontinence have a triple effect on incontinence symptoms, balance and functional status?

BACKGROUND

Improving pelvic floor muscle training (PFMT), balance and functional activity is recommended in the treatment of urinary incontinence (UI) in the elderly people. The aim of this study is to examine whether PFMT combined with Otago exercises is effective on symptoms, balance and functional status in elderly people with UI compared to PFMT alone.

METHODS

This study is an assessor-blinded, randomized controlled trial. Participants with UI aged 65 and over living in a nursing home were randomly assigned to the intervention (IG) and control groups (CG). The intervention group attended an exercise program that included Otago exercises combined with PFMT. The control group was included in the PFMT program with different positions. The duration of exercise for both groups was 45-60 min per session three times a week for 12 weeks. UI symptoms and severity (Pelvic Floor Distress Inventory-20, bladder diary), PFM muscle function (superficial electromyography), balance (Berg Balance Scale), functional status (Senior Fitness Test) and fear of falling (Falls Efficacy Scale) were measured at baseline and after the intervention.

RESULTS

The median age of the IG (n: 22) and CG (n: 21) was 73.5 and 77 years, respectively. At baseline and after the intervention within the group, a significant improvement was observed in the PTDE-20 score (IG and CG, p: 0.00) and the 2-min step test in the IG (p: 0.02) and CG (p: 0.01). A significant decrease was found in the 2.45 m get up-and-go test, PFM work average onset, and PFM rest MVC EMG values (p: 0.01, p: 0.01, p: 0.00) in the IG. The PFM rest average value decreased (p: 0.04) in the CG.

CONCLUSION

The findings of this study show that combining PFMT with Otago exercises, two evidence-based interventions, is beneficial for effectively treating incontinence symptoms, balance and functional status in elderly people. Thus, a triple effect can be achieved with a single exercise training in the same treatment session and for the same duration.

CLINICAL TRIAL NUMBER

Clinical trial number: NCT06331039.

Prevalence and outcomes of fear of falling in older adults with falls at the emergency department: a multicentric observational study

PURPOSE

Fear of falling (FOF) may result in activity restriction and deconditioning. The aim of the study was to identify factors associated with FOF in older patients and to investigate if FOF influenced long-term outcomes.

METHODS

Multicentric, observational, prospective study including patients 65 years or older attending the emergency department (ED) after a fall. Demographical, patient- and fall-related features were recorded at the ED. FOF was assessed using a single question. The primary outcome was all-cause death. Secondary outcomes included new fall-related visit, fall-related hospitalisation, and admission to residential care. Logistic regression and Cox regression models were used for statistical analyses.

RESULTS

Overall, 1464 patients were included (47.1% with FOF), followed for a median of 6.2 years (2.2-7.9). Seven variables (age, female sex, living alone, previous falls, sedative medications, urinary incontinence, and intrinsic cause of the fall) were directly associated with FOF whereas use of walking aids and living in residential care were inversely associated. After the index episode, 748 patients (51%) died (median 3.2 years), 677 (46.2%) had a new fall-related ED visit (median 1.7 years), 251 (17.1%) were hospitalised (median 2.8 years), and 197 (19.4%) were admitted to care (median 2.1 years). FOF was associated with death (HR 1.239, 95% CI 1.073-1.431), hospitalisation (HR 1.407, 95% CI 1.097-1.806) and institutionalisation (HR 1.578, 95% CI 1.192-2.088), but significance was lost after adjustment.

CONCLUSION

FOF is a prevalent condition in older patients presenting to the ED after a fall. However, it was not associated with long-term outcomes. Future research is needed to understand the influence of FOF in maintenance of functional capacity or quality of life.

Reducing Falls in Older Women with Urinary Incontinence

Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

Exercise as Medicine for Older Women

Exercise is associated with protective effects, yet most adult women in this country do not meet the physical activity recommendations set forth in the Physical Activity Guidelines for Americans. This article discusses how exercise affects disease and prevents functional decline. It also clarifies why exercise is not a generic cure-all but is instead a tool physicians can use with precision to affect a myriad of health issues. Specifics will be provided regarding physical fitness assessments and comprehensive treatments and how physicians can be more involved in using physical fitness to keep their older female patients healthy.

Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition)

The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.

Adaptation, validity and reliability of geriatric self-efficacy index for urinary incontinence (GSE-UI) in geriatric incontinents

PURPOSE

The purpose of this study was to translate and culturally adapt the GSE-UI for use with a Turkish population and to determine its validity and reliability.

METHODS

120 elderly with UI aged 60 and over years (mean 72.89 ± 9.59 years) participated in this study. An interview was held to determine the type, severity and frequency if any, incontinence. Then, the Mini-Mental State Examination, IIQ-7, UDI-6 and I-QOL questionnaires were administered to the participants. After translating the tool to Turkish, test and retest was performed with an interval of 7-14 days.

RESULTS

The internal consistency of the first test of the GSE-UI-Turkish was excellent, with a Cronbach α of 0.95. The test-retest reliability of the GSE-UI-Turkish was found to be excellent (ICC = 0.94, 95% CI 0.92-0.96). The correlation coefficient between the GSE-UI-Turkish and the UDI-6, IIQ-7, I-QOL were found to be good to excellent (r = 0.68, r = 0.67, r = 0.81, r = 0.45, respectively; p < 0.0001).

CONCLUSION

Results of our study GSE-UI of Turkish version, self-efficacy evaluation in geriatric incontinence was a valid and reliable survey that can be used in clinical practice.

Are Japanese Older Adults Rejuvenating? Changes in Health-Related Measures Among Older Community Dwellers in the Last Decade

During the last three decades, Japan has become one of the world's top countries for longevity, and the increase in average life expectancy is accompanied by a sharp rise in older population 65 years of age and above to ∼28%. This study aimed to examine the changes in major health-related measures, including a physical constitution, physical function, and functional capacity of community-dwelling Japanese older people in the last decade. From the data of 13 longitudinal cohort studies on aging conducted in Japan with a total of 13,441 older subjects, this study analyzed the changes in six indices that are related to health and functioning of the older people; height, weight, body mass index, walking speed, grip strength, and instrumental activity of daily living, between 2007 (±2 years) and 2017 (±2 years). Comparison of data for the two periods between subjects matched for age group and gender evidently showed better health status and a slower decline in most of the health-related measures in 2017 compared to a decade ago. The results of this study indicate that the phenomenon of "rejuvenation" is occurring among the new generation of Japanese older adults, and the importance of this older population as a social resource in the super-aged society should be reacknowledged.

Geriatric giants in women over 65 years living in a rural area in Turkey

The aim of this study was to determine the prevalence of fall tendency, urinary incontinence, and dementia in women over 65 years of age living in rural areas of Turkey. The research was a descriptive study. Mini-Mental tests, The International Consultation of Incontinence Questionnaire (ICIQ) short forms, and Falls Behavioral Scales for the elderly were used. Urinary incontinence prevalence in women over 65 years of age living in rural areas of Bursa was 51%. Dementia frequency was calculated as 56%. A reverse and significant relationship was detected between Mini-Mental Scale and ICIQ scale scores (r = -0.12; p = .017). The Falls Behavioral Scale score was higher in the group with incontinence. The conclusion reached was that urinary incontinence and dementia are frequent among older women living in rural areas in Turkey. As diseases known as geriatric giants are associated with each other, treatment of one of them may bring protection from another negative situation.

Combined group and home exercise programmes in community-dwelling falls-risk older adults: Systematic review and meta-analysis

OBJECTIVES

The objectives of this review were to (a) determine the effectiveness of combined group and home exercise programmes on falls risk factors and falls in community-dwelling older adults at risk of falling compared to no exercise controls; and (b) explore adherence and the behaviour change techniques employed in delivering these interventions.

METHODS

Five databases were selected to identify randomized controlled trials of exercise and/or physical activity interventions to prevent falls or to improve functional performance. PROSPERO CRD42018106111.

RESULTS

Eighteen trials involving 5,960 participants were included. Meta-analyses showed significant improvements in mobility after combined programmes measured by five times sit to stand (-1.42 times, 95% confidence interval [CI] -2.00 to -0.83), timed up and go (-0.94 s, 95% CI -1.76 to -0.12), and gait speed (0.05 m/s, 95% CI 0.02 to 0.07), but not single leg stance time, compared to controls. Combined programmes reduced injurious falls rate (0.77, 95% CI 0.65 to 0.91, I² = 0%) but not rate of falls (0.86, 95% CI 0.68 to 1.08, I² = 66%) compared to controls. There was no change in physical activity. Adherence ranged from 55-96%, with variability in the method of measurement of adherence. There was no clear relationship between adherence and outcomes. Most interventions used the behaviour change techniques of instruction/rehearsal/demonstration and feedback/monitoring.

CONCLUSION

Group exercise with a home programme resulted in better functional performance and falls-related outcomes compared with a no exercise control group. Further research is needed to identify behaviour change techniques to improve adherence to exercise in this population.

Effect of Weight Training with Pelvic Floor Muscle Training in Elderly Women with Urinary Incontinence

PURPOSE

To determine if weight training combined with pelvic floor muscle training is more efficient than pelvic floor muscle training alone for the treatment of urinary incontinence (UI) symptoms in elderly women.

METHOD

This was a two-arm, parallel, randomized controlled trial. Twenty-six women with stress UI participated in the study. The intervention group (IG) underwent training with moderate intensity weights combined with pelvic floor muscle training, whereas the control group (CG) only underwent pelvic floor muscle training. Intervention occurred twice a week over 12 weeks. The International Consultation on Incontinence Questionnaire-Short Form was used as the main measure. Scores of zero defined the absence of symptoms. The absence of symptoms was evaluated at 4 weeks, 12 weeks, and 1 month after the end of treatment. Moreover, activities related to UI and the use and change of daily protection were investigated.

RESULTS

The rate of absence of symptoms was significantly higher in IG after 4 weeks (58.3%) compared to CG (14.8%). The relative risk was 4.1 (95% confidence interval [CI] [1.08, 16.06]). Although no intention-to-treat analysis was performed, there was no difference in the evaluations after the interventions.

CONCLUSION

Compared to pelvic floor muscle training alone, the combination of weight training and pelvic floor muscle training provided earlier improvement of UI in elderly women.

Occupational Therapy Fall Prevention Interventions for Community-Dwelling Older Adults: A Systematic Review

OBJECTIVE

Accidental falls among community-dwelling older adults are preventable and increase the risk of morbidity, hospitalization, and institutionalization. We updated and broadened a 2008 systematic review examining the evidence for the effectiveness of fall prevention interventions in improving fall-related outcomes, occupational performance, quality of life, and health care facility readmissions for community-dwelling older adults.

METHOD

We searched and analyzed literature published from 2008 to 2015 from five electronic databases.

RESULTS

Fifty articles met the inclusion criteria and were critically appraised and synthesized-37 provided Level I; 5, Level II; and 8, Level III evidence. Analysis was organized into four intervention themes: single component, multicomponent, multifactorial, and population based. Mixed evidence was found for single-component and multifactorial interventions, strong evidence was found for multicomponent interventions, and moderate evidence was found for population-based interventions.

CONCLUSION

These findings can inform the delivery and integration of fall prevention interventions from acute care to community discharge.

Effects of exercise and nutrition education programs on motor function and eating habit in mild dementia patients

The purpose of this study was to investigate the effects of physical ac-tivity and nutrition education programs on mild dementia patients with changes in exercise function and eating habits. We examined the effects of pre and post program on 23 old patients with dementia who were diagnosed with menarche or mild dementia with the permission of the dementia center in Incheon city and visited from April to July 2017. The Mini-Mental State Examination score of the subjects in this study was 19.68±3.25, consisting of mild dementia patients. After performing the program for 16 weeks, the senior fitness test showed a significant change in the arm curl test, chair sit-and-reach test, and 2-min step test, and a total score of mini nutrition assessment increased from 19.16 to 21.0. In particular, in a level 2 evaluation, which contains more details such as the condition of taking drugs, number of daily meals, protein food intake condition, intake of vegetables, fruit, and water, whether one can eat alone, and evaluation of nutritive condition, a significant increase from 9.78 to 11.28 was verified. There is a significant increase in nutrition condition recovery as a result of nutrition education. In comparing pre and post program, a significant result was confirmed, and there was significance to provide the basic empirical data for the exercise and dietary life nutritional education of mild dementia patients.

Fear of falling among community-dwelling older adults: A scoping review to identify effective evidence-based interventions

Fear of falling presents a significant problem for many older adults by reducing physical function and increasing the risk of future falls. Several different types of interventions have improved fear of falling and a summary of efficacious interventions will help clinicians recommend treatment options. Using the Arksey and O'Malley Framework for scoping reviews, the purpose of this review was to identify efficacious interventions for treating fear of falling among community-dwelling older adults in order to provide a list of potential treatment options for care providers. A total of 45 publications were identified for inclusion in this review.

Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial

Background

Somatic afferent nerve stimuli are used for treating an overactive bladder (OAB), a major cause of nocturia in the elderly. Clinical evidence for this treatment is insufficient because of the lack of appropriate control stimuli. Recent studies on anesthetized animals show that gentle stimuli applied to perineal skin with a roller could inhibit micturition contractions depending on the roller’s surface material. We examined the efficacy of gentle skin stimuli for treating nocturia.

Methods

The study was a cross-over, placebo-controlled, double-blind randomized clinical study using two rollers with different effects on micturition contractions. Participants were elderly women (79–89 years) with nocturia. Active (soft elastomer roller) or placebo (hard polystyrene roller) stimuli were applied to perineal skin by participants for 1 min at bedtime. A 3-day baseline assessment period was followed by 3-day stimulation and 4-day resting periods, after which the participants were subjected to other stimuli for another 3 days. The primary outcome was change in the frequency of nighttime urination, for which charts were maintained during each 3-day period.

Results

Twenty-four participants were randomized, of which 22 completed all study protocols. One participant discontinued treatment because of an adverse event (abdominal discomfort). In participants with OAB (n = 9), change from baseline in the mean frequency of urination per night during the active stimuli period (mean ± standard deviation, −0.74 ± 0.7 times) was significantly greater than that during placebo stimuli periods (−0.15 ± 0.8 times [p < 0.05]). In contrast, this difference was not observed in participants without OAB (n = 13).

Conclusions

These results suggest that gentle perineal stimulation with an elastomer roller is effective for treating OAB-associated nocturia in elderly women. Here the limitation was a study period too short to assess changes in the quality of sleep and life.

Trial Registration

UMIN Clinical Trial Registry (CTR) UMIN000015809

Clinical Guideline for Female Lower Urinary Tract Symptoms

The "Japanese Clinical Guideline for Female Lower Urinary Tract Symptoms," published in Japan in November 2013, contains two algorithms (a primary and a specialized treatment algorithm) that are novel worldwide as they cover female lower urinary tract symptoms other than urinary incontinence. For primary treatment, necessary types of evaluation include querying the patient regarding symptoms and medical history, examining physical findings, and performing urinalysis. The types of evaluations that should be performed for select cases include evaluation with symptom/quality of life (QOL) questionnaires, urination records, residual urine measurement, urine cytology, urine culture, serum creatinine measurement, and ultrasonography. If the main symptoms are voiding/post-voiding, specialized treatment should be considered because multiple conditions may be involved. When storage difficulties are the main symptoms, the patient should be assessed using the primary algorithm. When conditions such as overactive bladder or stress incontinence are diagnosed and treatment is administered, but sufficient improvement is not achieved, the specialized algorithm should be considered. In case of specialized treatment, physiological re-evaluation, urinary tract/pelvic imaging evaluation, and urodynamic testing are conducted for conditions such as refractory overactive bladder and stress incontinence. There are two causes of voiding/post-voiding symptoms: lower urinary tract obstruction and detrusor underactivity. Lower urinary tract obstruction caused by pelvic organ prolapse may be improved by surgery.

What type, or combination of exercise can improve preferred gait speed in older adults? A meta-analysis

BACKGROUND

Improved preferred gait speed in older adults is associated with increased survival rates. There are inconsistent findings in clinical trials regarding effects of exercise on preferred gait speed, and heterogeneity in interventions in the current reviews and meta-analyses.

OBJECTIVE

to determine the meta-effects of different types or combinations of exercise interventions from randomized controlled trials on improvement in preferred gait speed.

METHODS

DATA SOURCES

A literature search was performed; the following databases were searched for studies from 1990 up to 9 December 2013: PubMed, EMBASE, EBSCO (AMED, CINAHL, ERIC, Medline, PsycInfo, and SocINDEX), and the Cochrane Library.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials of exercise interventions for older adults ≥ 65 years, that provided quantitative data (mean/SD) on preferred gait speed at baseline and post-intervention, as a primary or secondary outcome measure in the published article were included. Studies were excluded when the PEDro score was ≤4, or if participants were selected for a specific neurological or neurodegenerative disease, Chronic Obstructive Pulmonary Disease, cardiovascular disease, recent lower limb fractures, lower limb joint replacements, or severe cognitive impairments. The meta-effect is presented in Forest plots with 95 % confidence

STUDY APPRAISAL AND SYNTHESIS METHODS

intervals and random weights assigned to each trial. Homogeneity and risk of publication bias were assessed.

RESULTS

Twenty-five studies were analysed in this meta-analysis. Data from six types or combinations of exercise interventions were pooled into sub-analyses. First, there is a significant positive meta-effect of resistance training progressed to 70-80 % of 1RM on preferred gait speed of 0.13 [CI 95 % 0.09-0.16] m/s. The difference between intervention- and control groups shows a substantial meaningful change (>0.1 m/s). Secondly, a significant positive meta-effect of interventions with a rhythmic component on preferred gait speed of 0.07 [CI 95 % 0.03-0.10] m/s was found. Thirdly, there is a small significant positive meta-effect of progressive resistance training, combined with balance-, and endurance training of 0.05 [CI 95 % 0.00-0.09] m/s. The other sub-analyses show non-significant small positive meta-affects.

CONCLUSIONS

Progressive resistance training with high intensities, is the most effective exercise modality for improving preferred gait speed. Sufficient muscle strength seems an important condition for improving preferred gait speed. The addition of balance-, and/or endurance training does not contribute to the significant positive effects of progressive resistance training. A promising component is exercise with a rhythmic component. Keeping time to music or rhythm possibly trains higher cognitive functions that are important for gait.

LIMITATIONS

The focus of the present meta-analysis was at avoiding as much heterogeneity in exercise interventions. However heterogeneity in the research populations could not be completely avoided, there are probably differences in health status within different studies.

The effect of pelvic floor muscle training in urinary incontinent elderly women: a sistematic review

Introduction The International Continence Society (ICS) determines that the pelvic floor muscles training (PFMT) is the first-choice treatment of urinary symptoms in women. Objective The aim of this study was to systematize randomized controlled clinical trials that address the effects of PFMT in the treatment of urinary symptoms in older women using objective outcome measures. Method Systematic review search was performed eletronic the following databases: Medline, Pubmed, Lilacs, PEDro and manual research conducted in the references of the studies. Were considered eligible women aged over 60 years who performed PFMT in isolation, without the involvement of another technique. The PFMT performed in clinic or at home, with or without the supervision of a therapist and with or without the use of biofeedback as an adjunct. Considered as outcome measures urodynamic studies, voiding diary that assesses daytime urinary frequency, nocturnal urinary frequency, urinary incontinence and exchange absorbent, and, finally, the absorbent test that quantifies loss urinary grams. The assessment of methodological quality of the studies was conducted by PEDro scale. Results Three studies were reviewed in full. Only one trial was rated high methodological quality. There was significant improvement in urinary symptoms after treatment proposed in the three selected studies. Conclusion Considering the studies available so far are weak the evidence for the use of PFMT in the treatment of urinary symptoms in elderly women.

Exercise for reducing fear of falling in older people living in the community

BACKGROUND

Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned, structured, repetitive and purposive physical activity aimed at improving physical fitness) may reduce fear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls.

OBJECTIVES

To assess the effects (benefits, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Week 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 to July 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Organization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts.

SELECTION CRITERIA

We included randomised and quasi-randomised trials that recruited community-dwelling people (where the majority were aged 65 and over) and were not restricted to specific medical conditions (e.g. stroke, hip fracture). We included trials that evaluated exercise interventions compared with no intervention or a non-exercise intervention (e.g. social visits), and that measured fear of falling. Exercise interventions were varied; for example, they could be 'prescriptions' or recommendations, group-based or individual, supervised or unsupervised.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for inclusion, assessed the risk of bias in the studies and extracted data. We combined effect sizes across studies using the fixed-effect model, with the random-effect model used where significant statistical heterogeneity was present. We estimated risk ratios (RR) for dichotomous outcomes and incidence rate ratios (IRR) for rate outcomes. We estimated mean differences (MD) where studies used the same continuous measures and standardised mean differences (SMD) where different measures or different formats of the same measure were used. Where possible, we performed various, usually prespecified, sensitivity and subgroup analyses.

MAIN RESULTS

We included 30 studies, which evaluated 3D exercise (Tai Chi and yoga), balance training or strength and resistance training. Two of these were cluster-randomised trials, two were cross-over trials and one was quasi-randomised. The studies included a total of 2878 participants with a mean age ranging from 68 to 85 years. Most studies included more women than men, with four studies recruiting women only. Twelve studies recruited participants at increased risk of falls; three of these recruited participants who also had fear of falling.Poor reporting of the allocation methods in the trials made it difficult to assess the risk of selection bias in most studies. All of the studies were at high risk of performance and detection biases as there was no blinding of participants and outcome assessors and the outcomes were self reported. Twelve studies were at high risk of attrition bias. Using GRADE criteria, we judged the quality of evidence to be 'low' for fear of falling immediately post intervention and 'very low' for fear of falling at short or long-term follow-up and all other outcomes.Exercise interventions were associated with a small to moderate reduction in fear of falling immediately post intervention (SMD 0.37 favouring exercise, 95% confidence interval (CI) 0.18 to 0.56; 24 studies; 1692 participants, low quality evidence). Pooled effect sizes did not differ significantly between the different scales used to measure fear of falling. Although none of the sensitivity analyses changed the direction of effect, the greatest reduction in the size of the effect was on removal of an extreme outlier study with 73 participants (SMD 0.24 favouring exercise, 95% CI 0.12 to 0.36). None of our subgroup analyses provided robust evidence of differences in effect in terms of either the study primary aim (reduction of fear of falling or other aim), the study population (recruitment on the basis of increased falls risk or not), the characteristics of the study exercise intervention or the study control intervention (no treatment or alternative intervention). However, there was some weak evidence of a smaller effect, which included no reduction, of exercise when compared with an alternative control.There was very low quality evidence that exercise interventions may be associated with a small reduction in fear of falling up to six months post intervention (SMD 0.17, 95% CI -0.05 to 0.38; four studies, 356 participants) and more than six months post intervention (SMD 0.20, 95% CI -0.01 to 0.41; three studies, 386 participants).Very low quality evidence suggests exercise interventions in these studies that also reported on fear of falling reduced the risk of falling measured either as participants incurring at least one fall during follow-up or the number of falls during follow-up. Very low quality evidence from four studies indicated that exercise interventions did not appear to reduce symptoms of depression or increase physical activity. The only study reporting the effects of exercise interventions on anxiety found no difference between groups. No studies reported the effects of exercise interventions on activity avoidance or costs. It is important to remember that our included studies do not represent the totality of the evidence of the effect of exercise interventions on falls, depression, anxiety or physical activity as our review only includes studies that reported fear of falling.

AUTHORS' CONCLUSIONS

Exercise interventions in community-dwelling older people probably reduce fear of falling to a limited extent immediately after the intervention, without increasing the risk or frequency of falls. There is insufficient evidence to determine whether exercise interventions reduce fear of falling beyond the end of the intervention or their effect on other outcomes. Although further evidence from well-designed randomised trials is required, priority should be given to establishing a core set of outcomes that includes fear of falling for all trials examining the effects of exercise interventions in older people living in the community.

Do continence management strategies reduce falls? a systematic review

Urinary incontinence is associated with increased fall risk, and fall prevention programs include recommendations to manage continence as one component of fall reduction. However, the evidence to support this recommendation is unclear. The aim of this study was to identify continence management interventions that are effective in decreasing falls. A systematic review of the literature was conducted. Studies were included if they evaluated the effect of any type of continence management strategy on falls in older adults. The included studies were assessed for quality, and data relating to participants, interventions and outcomes were extracted by two independent reviewers. Four articles met the inclusion criteria. Two studies were randomised controlled trials, one a retrospective cohort study and one an uncontrolled intervention study. Interventions included pharmacological agents, a toileting regime combined with physical activity and an individualised continence program. Only the study evaluating the combination of physical activity and prompted voiding found an effect on falls. It is surprising that there has been so little research into continence management interventions that include fall outcomes. A toileting regime combined with physical activity may reduce falls in residential care. There is a need for further studies investigating the impact of continence management on falls.

Hip fracture and urinary incontinence--use of indwelling catheter postsurgery

BACKGROUND

Norway has a higher incidence of hip fractures than any other country. For older individuals, a hip fracture may cause dramatic changes in health status like incontinence and daily activities. Patients with hip fractures are at high risk of urinary incontinence (UI) after surgical repair. A urinary indwelling catheter (UIC) is inserted preoperatively, but should be removed within 24 hours. Our aims were to identify indicators that might predict clinical challenges related to urinary incontinence 1 year after hip fractures.

METHODS

Inclusion criteria were patients with hip fracture age 65 years or older. They were admitted form their own home to two acute-care hospitals during 2004-2006. We used the Resident Assessment Instrument for Acute Care.

RESULTS

A total of 331 patients were included. Thirty-five (11%) had UIC 72 hours after surgery. These patients had more frequently experienced delirium, urinary tract infection, cognitive impairment and discouragement than their counterparts. After 12 months, patients with previous UI had lower functioning levels than those with no previous UI. They had moved four times more frequently to a nursing home and had over twice the mortality.

CONCLUSIONS

Patient with UI should be followed up with a multidisciplinary team after discharged from hospital.

How safe is your neighborhood? Perceived neighborhood safety and functional decline in older adults

BACKGROUND

Neighborhood characteristics are associated with health and the perception of safety is particularly important to exercise and health among older adults. Little is known about the relationship between perception of neighborhood safety and functional decline in older adults.

OBJECTIVE

To determine the relationship between perceived neighborhood safety and functional decline in older adults.

DESIGN/SETTING

Longitudinal, community-based.

PARTICIPANTS

18,043 persons, 50 years or older, who participated in the 1998 and 2008 Health and Retirement Study.

MAIN MEASURES

The primary outcome was 10-year functional decline (new difficulty or dependence in any Activity of Daily Living, new mobility difficulty, and/or death). The primary predictor was perceived neighborhood safety categorized into three groups: "very safe", "moderately safe", and "unsafe." We evaluated the association between perceived neighborhood safety and 10-year functional decline using a modified Poisson regression to generate unadjusted and adjusted relative risks (ARR).

KEY RESULTS

At baseline 11,742 (68.0%) participants perceived their neighborhood to be very safe, 4,477 (23.3%) moderately safe, and 1,824 (8.7%) unsafe. Over 10 years, 10,338 (53.9%) participants experienced functional decline, including 6,266 (50.2%) who had perceived their neighborhood to be very safe, 2,839 (61.2%) moderately safe, and 1,233 (63.6%) unsafe, P < 0.001. For the 11,496 (63.3%) of participants who were functionally independent at baseline, perceived neighborhood safety was associated with 10-year functional decline (moderately safe ARR 1.15 95% CI 1.09-1.20; unsafe ARR 1.21 95% CI: 1.03-1.31 compared to very safe group). The relationship between perceived neighborhood safety and 10-year functional decline was not statistically significant for participants who had baseline functional impairment.

CONCLUSION

Asking older adults about their perceived neighborhood safety may provide important information about their risk of future functional decline. These findings also suggest that future studies might focus on assessing whether interventions that promote physical activity while addressing safety concerns help reduce functional decline in older adults.