Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis

Background

Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement.

Objectives

To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect.

Review design

Systematic review and network meta-analysis.

Eligibility criteria

Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention.

Main outcomes

Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year.

Data sources

We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists.

Review methods

Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis).

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive.

Limitations

High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts.

Conclusions

Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence.

Future work

Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.

Study registration

This study is registered as PROSPERO CRD42019162195.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Physical Activity in South Asian Indians: A Systematic Review of Randomized Controlled Trials

This review systematically examines the characteristics and effectiveness of randomized controlled trials with aerobic physical activity (PA) interventions tailored to South Asian Indians (SAIs). PubMed/MEDLINE, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar were searched. The search yielded 1,842 studies; 11 met the criteria. The Center for Evidence-Based Medicine's critical appraisal tool was used to assess the quality of studies. Studies that used supervised structured PA sessions, educational material in SAI languages, motivational strategies, and positive reinforcement for goal setting, reported significant improvement in PA (p < .05; Cohen's d ≤ 0.3 to >0.8). Future PA studies in India featuring SAIs would benefit from clinic-based one-on-one structured aerobic PA interventions. In contrast, SAI immigrants in Western countries would benefit from community-based structured aerobic PA interventions that are offered in groups and culturally adapted.

Effectiveness of multicomponent home-based rehabilitation in older patients after hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Hip fracture is a major burden on health care systems worldwide and requires hospitalisation for a long period.

OBJECTIVE

The aim was to evaluate the effectiveness of multicomponent home-based rehabilitation compared with different control interventions (in-hospital rehabilitation, active control or usual care) in older patients after hip fracture surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled studies.

DATA SOURCES

We searched three electronic databases, including Ovid-MEDLINE, Ovid-Embase, CINAHL and the Cochrane Library for relevant articles up to March 2020.

REVIEW METHODS

Two investigators independently extracted data and assessed study quality using the risk of bias. Data were analysed using Review Manager 5.3. The current review employs the PRISMA procedure.

RESULTS

Out of 2996 studies, 22 articles were relevant for this review and meta-analysis. Among them, five compared the multicomponent home-based rehabilitation with in-hospital rehabilitation, one compared it with active control, six with usual care and ten compared the home exercise only with usual care. There was no significant difference in activities of daily living (ADL) between multicomponent home-based rehabilitation and in-hospital rehabilitation, while multicomponent home-based rehabilitation significantly increased in ADL when compared to usual care. Home exercises also had significant effects on ADL, quality of life(QoL), balance, gait and muscle strength of the knee extensor compared with usual care (p < .05).

CONCLUSIONS

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL.

RELEVANT TO CLINICAL PRACTICE

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL. Also, high adherence to home exercise may be associated with better clinical outcomes. Therefore, more compliance-oriented multicomponent home-based rehabilitation programmes for older patients after hip fracture must be developed by health care professionals, including physical therapist, to ensure optimum home-based rehabilitation.

Physical Activity Counseling in Saudi Arabia: A Systematic Review of Content, Outcomes, and Barriers

OBJECTIVES

This study aimed to map the characteristics and the predominant components of clinical physical activity (PA) counseling in Saudi Arabia for adult patients and outline evidence of outcomes and prevalent barriers to its implementation.

METHODS

We conducted a systematic literature search of four online databases: Web of Science, PubMed, ScienceDirect, and The Cochrane Library. Each study was assessed and evaluated using the Mixed Methods Appraisal Tool (MMAT) for methodological quality.

RESULTS

A total of 120 studies were screened, and 47 studies were sought for retrieval. In total, 25 articles were eligible and were subjected to extensive review. After a detailed evaluation, only nine studies met the inclusion criteria. All included were quantitative studies that compiled descriptive and numerical data on physical activity counseling. Four studies described PA counseling information in Saudi Arabia or prescription as lifestyle modification and program structure. The programs used various techniques to motivate patients to adhere to PA protocols. In general, practitioners indicated a high perceived competence in helping patients meet PA guidelines. The most frequently stated barrier was a lack of time for PA discussions with patients, followed by a lack of training in PA counseling, and a lack of patient compliance. Significant improvements in clinical parameters and smoking, food, and exercise habits were detected in experimental trials with respective intervention programs.

CONCLUSION

This review provides preliminary insights into the delivered intervention and standard care content, its outcomes, and clinicians' perceived competence and barriers regarding current PA counseling approaches in Saudi Arabia. Despite the small number of studies included, this review contributes to the limited understanding of current PA counseling practices in Saudi Arabia and serves as an informational source for clinicians and policymakers and a starting point for further research.

Impact of physical activity programs and services for older adults: a rapid review

Background

Knowledge of which physical activity programs are most effective for older adults in different sub-populations and contexts is limited. The objectives of this rapid review were to: 1) Overview evidence evaluating physical activity programs/services for older adults; and 2) Describe impact on physical activity, falls, intrinsic capacity (physical domain), functional ability (physical, social, and cognitive/emotional domains), and quality of life.

Methods

We conducted a rapid review of primary studies from 350 systematic reviews identified in a previous scoping review (March 2021: PEDro, MEDLINE, CINAHL, Cochrane Database). For Objective 1, we included intervention studies investigating physical activity programs/services in adults ≥ 60 years. Of these, we included good quality (≥ 6/10 PEDro scale) randomised controlled trials (RCTs) with ≥ 50 participants per group in Objective 2.

Results

Objective 1: Of the 1421 intervention studies identified from 8267 records, 79% were RCTs, 87% were in high income countries and 39% were good quality. Objective 2: We identified 87 large, good quality RCTs (26,861 participants). Overall activity promotion, structured exercise and recreation/sport had positive impacts (≥ 50% between-group comparisons positive) across all outcome domains. For overall activity promotion (21 intervention groups), greatest impacts were on physical activity (100% positive) and social outcomes (83% positive). Structured exercise (61 intervention groups) had particularly strong impacts on falls (91% positive), intrinsic capacity (67% positive) and physical functioning (77% positive). Recreation/sport (24 intervention groups) had particularly strong impacts on cognitive/emotional functioning (88% positive). Multicomponent exercise (39 intervention groups) had strong impacts across all outcomes, particularly physical activity (95% positive), falls (90% positive) and physical functioning (81% positive). Results for different populations and settings are presented.

Conclusion

Evidence supporting physical activity for older adults is positive. We outline which activity types are most effective in different populations and settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01318-9.

Interventions for reducing sedentary behaviour in community-dwelling older adults

BACKGROUND

Older adults are the most sedentary segment of society, often spending in excess of 8.5 hours a day sitting. Large amounts of time spent sedentary, defined as time spend sitting or in a reclining posture without spending energy, has been linked to an increased risk of chronic diseases, frailty, loss of function, disablement, social isolation, and premature death.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at reducing sedentary behaviour amongst older adults living independently in the community compared to control conditions involving either no intervention or interventions that do not target sedentary behaviour.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, EPPI-Centre databases (Trials Register of Promoting Health Interventions (TRoPHI) and the Obesity and Sedentary behaviour Database), WHO ICTRP, and ClinicalTrials.gov up to 18 January 2021. We also screened the reference lists of included articles and contacted authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs. We included interventions purposefully designed to reduce sedentary time in older adults (aged 60 or over) living independently in the community. We included studies if some of the participants had multiple comorbidities, but excluded interventions that recruited clinical populations specifically (e.g. stroke survivors).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and full-text articles to determine study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted authors for additional data where required. Any disagreements in study screening or data extraction were settled by a third review author.

MAIN RESULTS

We included seven studies in the review, six RCTs and one cluster-RCT, with a total of 397 participants. The majority of participants were female (n = 284), white, and highly educated. All trials were conducted in high-income countries. All studies evaluated individually based behaviour change interventions using a combination of behaviour change techniques such as goal setting, education, and behaviour monitoring or feedback. Four of the seven studies also measured secondary outcomes. The main sources of bias were related to selection bias (N = 2), performance bias (N = 6), blinding of outcome assessment (N = 2), and incomplete outcome data (N = 2) and selective reporting (N=1). The overall risk of bias was judged as unclear. Primary outcomes The evidence suggests that interventions to change sedentary behaviour in community-dwelling older adults may reduce sedentary time (mean difference (MD) -44.91 min/day, 95% confidence interval (CI) -93.13 to 3.32; 397 participants; 7 studies; I2 = 73%; low-certainty evidence). We could not pool evidence on the effect of interventions on breaks in sedentary behaviour or time spent in specific domains such as TV time, as data from only one study were available for these outcomes. Secondary outcomes We are uncertain whether interventions to reduce sedentary behaviour have any impact on the physical or mental health outcomes of community-dwelling older adults. We were able to pool change data for the following outcomes. • Physical function (MD 0.14 Short Physical Performance Battery (SPPB) score, 95% CI -0.38 to 0.66; higher score is favourable; 98 participants; 2 studies; I2 = 26%; low-certainty evidence). • Waist circumference (MD 1.14 cm, 95% CI -1.64 to 3.93; 100 participants; 2 studies; I2 = 0%; low-certainty evidence). • Fitness (MD -5.16 m in the 6-minute walk test, 95% CI -36.49 to 26.17; higher score is favourable; 80 participants; 2 studies; I2 = 29%; low-certainty evidence). • Blood pressure: systolic (MD -3.91 mmHg, 95% CI -10.95 to 3.13; 138 participants; 3 studies; I2 = 73%; very low-certainty evidence) and diastolic (MD -0.06 mmHg, 95% CI -5.72 to 5.60; 138 participants; 3 studies; I2 = 97%; very low-certainty evidence). • Glucose blood levels (MD 2.20 mg/dL, 95% CI -6.46 to 10.86; 100 participants; 2 studies; I2 = 0%; low-certainty evidence). No data were available on cognitive function, cost-effectiveness or adverse effects.

AUTHORS' CONCLUSIONS

It is not clear whether interventions to reduce sedentary behaviour are effective at reducing sedentary time in community-dwelling older adults. We are uncertain if these interventions have any impact on the physical or mental health of community-dwelling older adults. There were few studies, and the certainty of the evidence is very low to low, mainly due to inconsistency in findings and imprecision. Future studies should consider interventions aimed at modifying the environment, policy, and social and cultural norms. Future studies should also use device-based measures of sedentary time, recruit larger samples, and gather information about quality of life, cost-effectiveness, and adverse event data.

Transitions between levels of dependency among older people receiving social care - a retrospective longitudinal cohort study in a Swedish municipality

Background

Knowledge is scarce on how needs for home help and special housing evolve among older people who begin to receive support from municipal social care. The purpose of this study was to describe baseline distributions and transitions over time between levels of dependency among older persons after being granted social care in a Swedish municipality.

Methods

Based on a longitudinal cohort study in a Swedish municipality, data was collected retrospectively from municipal records. All persons 65 years or older who received their first decision on social care during 2010 (n = 415) were categorized as being in mild, moderate, severe, or total dependency, and were observed until the end of 2013. Baseline distributions and transitions over time were described descriptively and analysed with survival analysis, with the Kaplan-Meier estimator, over the entire follow-up period. To test potential differences in relation to gender, we used the Cox-Proportional hazards model.

Results

Baseline distributions between mild, moderate, severe, and total dependency were 53, 16, 24, and 7.7%. During the first year, between 40 and 63% remained at their initial level of dependency. Among those with mild and moderate levels of dependency at baseline, a large proportion declined towards increasing levels of dependency over time; around 40% had increased their dependency level 1 year from baseline and at the end of the follow-up, 75% had increased their dependency level or died.

Conclusions

Older people in Sweden being allocated home help are at high risk for decline towards higher levels of dependency, especially those at mild or moderate dependency levels at baseline. Taken together, it is important that municipalities make use of existing knowledge so that they implement cost-effective preventative interventions for older people at an early stage before a decline toward increasing levels of dependency.

Practical implications for providing physical activity counseling for the older adult: An integrative review

BACKGROUND

Physical inactivity in the older adult is associated with functional decline, increased fall risk, and threatens the ability of the older adult to live independently. Nurse practitioners, with their expertise in health promotion and chronic disease management, are well positioned to provide physical activity (PA) counseling. However, there is a gap in the literature describing a practical formula for providing PA counseling and PA prescriptions for clinical practice.

OBJECTIVE

The objective of this integrative review was to synthesize the literature related to counseling interventions designed to increase PA among older adults and provide practical recommendations for incorporating recommendations into practice.

DATA SOURCES

Five different databases were searched along with ancestry searching of relevant articles. Eligible studies tested methods of recommending PA for adults age ≥65 years, including in-person counseling, phone calls, written information, and exercise prescriptions.

CONCLUSIONS

Health care providers are able to motivate older adults to increase PA in the short term. Diverse health care disciplines are efficacious at motivating older adults to increase PA. Various counseling interventions can be used with varying amounts of time investment.

IMPLICATIONS FOR PRACTICE

Physical activity counseling is an underused but effective intervention for increasing PA in older adults. Older adults respond well to advice to increase their PA especially with the addition of a written exercise prescription. Basing PA counseling interventions on a theoretical construct such as social cognitive theory or transtheoretical stages of change theory improves the efficacy of the interventions.

Group Dance and Motivational Coaching for Walking: A Physical Activity Program for South Asian Indian Immigrant Women Residing in the United States

BACKGROUND

South Asian Indian immigrants residing in the United States are at high risk of cardiovascular disease (prevalence ≥35%), diabetes (prevalence 45.4%), and stroke (prevalence 26.5%). This study examined the effect of culturally relevant physical activity interventions on the improvement of physiological measures and average daily steps in at-risk midlife South Asian Indian immigrant women.

METHODS

In this 2-arm interventional research design, the dance (n = 25) and the motivational phone calls group (n = 25), attended social cognitive theory-based motivational workshops every 2 weeks for the first 12 weeks. Data for weight, waist circumference, blood pressure, blood sugar, cholesterol level, and 12-lead electrocardiogram were collected at the baseline, 12 weeks, and 24 weeks.

RESULTS

Significant differences were seen in body weight (F2,94 = 4.826, P = .024; ηp2=.093), waist circumference (F2,92 = 7.496, P = .001; ηp2=.140), systolic blood pressure (F2,94 = 19.865, P = .000; ηp2=.2970), triglyceride (F2,94 = 11.111, P = .000; ηp2=.191), cholesterol (F2,94 = 8.925, P = .001; ηp2=.160), blood sugar level (F2,94 = 8.851, P = .000; ηp2=.158), and average daily steps across both intervention groups over time (F2,96 = 30.94, P = .000; ηp2=.392).

CONCLUSION

Culturally relevant motivational workshops with Indian dance and walking are an innovative approach to increasing lifestyle physical activity among South Asian Indian immigrant women.

The effect of individualized, theory-based counselling intervention on active aging and quality of life among older people (the AGNES intervention study)

BACKGROUND

We define active aging as a striving for activities as per one's goals, capacities and opportunities.

AIM

To test the 1-year counselling intervention effects on active aging.

METHODS

In this two-arm single-blinded randomized controlled trial, the intervention group received individually tailored counselling supporting autonomous motivation for active life (one face-to-face session, four phone calls and supportive written material, n = 101) and the control group written health information (n = 103). Participants were community-dwelling men and women aged 75 or 80 years with intermediate mobility function and without cognitive impairment. The primary outcome was active aging total score measured with the University of Jyväskylä Active Aging Scale (UJACAS, range 0-272, higher values indicate more activity) and secondary outcomes were its subscores for goals, ability, opportunity and activity (range 0-68) and a quality of life (QoL) score. Measures took place at pre-trial, mid-trial (6 months) and post-trial (12 months), except for QoL only pre and post-trial. Data were analyzed with intention-to-treat principles using GEE-models.

RESULTS

The UJACAS total score increased in the intervention group slightly more than in the control group (group by time p-value = 0.050, effect size 0.011, net benefit 2%), but the group effect was not statistically significant. A small effect was observed for the activity subscore (p = 0.007).

DISCUSSION

The individualized counselling supporting autonomous motivation for active life increased the UJACAS score slightly.

CONCLUSIONS

It may be possible to promote active aging with individualized counselling, but the effect is small and it is unclear whether the change is meaningful.

Effects of an Individualized Active Aging Counseling Intervention on Mobility and Physical Activity: Secondary Analyses of a Randomized Controlled Trial

Objectives: The aim of this study was to report preplanned secondary analyses of the effects of a 12-month individualized active aging counseling intervention on six mobility and physical activity outcomes. Methods: A two-arm, single-blinded randomized controlled trial was conducted among 75- and 80-year-old community-dwelling people. The intervention group (IG, n = 101) received counseling aimed at increasing self-selected, primarily out-of-home activity. The control group (CG, n = 103) received general health information. Data were analyzed with generalized estimating equations. Results: Physical performance improved in the IG more than that in the CG (group by time p = .022), self-reported physical activity increased in both groups (time p = .012), and autonomy in outdoor mobility declined in the IG and was enhanced in the CG (group by time p = .011). No change was observed for life-space mobility, proportion of persons perceiving difficulty walking 2 km, or monitored physical activity. Discussion: Individualized counseling aiming at increasing self-selected out-of-home activity had nonsystematic effects on mobility and positively affected physical performance only.

Exploring reach and experiences of participation in health-promoting senior meetings in a municipality context

Aim

To explore reach and experiences of participants during implementation of health-promoting meetings of seniors in a Swedish municipality context.

Subjects and methods

A mixed-methods approach was used, including older people who were recruited consecutively and invited to participate as they applied for health care and/or home help services in the municipality. Inclusion criterion was allocation of “early” home-care services, e.g., meals on wheels, safety alarms. Health-care services were limited to persons applying for an outside walker. The intervention was multi-professional, e.g., occupational therapy and physiotherapy. Each session included a mix of short lectures and group discussions about, for example, the importance of engagement in meaningful activity, social contacts, and physical activity. Recruitment procedures were modified during the trial in order to enhance reach. The data collection included information on the flow of participants during recruitment and participation in the intervention, field notes covering the experience of implementing the intervention, a survey covering adherence to recruitment procedures, and qualitative interviews exploring the experience of participants.

Results

Senior meetings were experienced as positive and strengthened the participants in dealing with health-related concerns. The identification of potential participants and recruitment were challenging, but as recruitment procedures were modified, a higher proportion of potential participants were reached. In all, there were 29 participants over the study period.

Conclusion

For health-promoting meetings to enable community-dwelling older people to fulfill their potential by positively affecting health outcomes, recruitment procedures for optimizing reach is a critical feature.

Counselling for physical activity, life-space mobility and falls prevention in old age (COSMOS): protocol of a randomised controlled trial

INTRODUCTION

The most promising way to promote active life years in old age is to promote regular participation in physical activity (PA). Maintaining lower extremity muscle function with good balance has been associated with fewer falls and the need of help from others. This article describes the design and intervention of a randomised controlled trial (RCT) investigating the effectiveness of a health and PA counselling programme on life-space mobility and falls rates in community-dwelling older adults at the Health Kiosk and/or Service Centre.

METHODS AND ANALYSIS

Community-dwelling men and women (n=450) aged 65 years and over with early phase mobility limitation will be recruited to a 24-month RCT with a 24-month follow-up. Participants will be randomly allocated into either a health and PA counselling group (intervention) or relaxation group (control intervention). All participants will receive five group specific face-to-face counselling sessions and 11 phone calls. The counselling intervention will include individualised health counselling, strength and balance training, and guidance to regular PA. The control group will receive relaxation exercises. Outcomes will be assessed at baseline, 12, 24 and 48 months. Primary outcomes are average life-space mobility score and falls rates. Life-space mobility will be assessed by a validated questionnaire. Falls rates will be recorded from fall diaries. Secondary outcomes are data on fall-induced injuries and living arrangements, number of fallers, fracture risk, mean level of PA, physical performance, quality of life, mood, cognition, balance confidence and fear of falling. Data will be analysed using the intention-to-treat principle. Cost-effectiveness of the programme will be analysed. Ancillary analyses are planned in participants with greater adherence.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee of the Tampere University Hospital (R15160). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences.

TRIAL REGISTRATION

ISRCTN65406039; Pre-results.

Individualized counselling for active aging: protocol of a single-blinded, randomized controlled trial among older people (the AGNES intervention study)

BACKGROUND

Active aging has been established as a policy goal for aging societies. We define active aging at the individual level as striving for elements of well-being through activities in relation to a person's goals, functional capacities and opportunities. Increasing evidence suggests that any meaningful activity is beneficial for different aspects of well-being in older people. The aim of the present randomized controlled trial is to test the feasibility and effectiveness of a one-year community-based intervention on active aging. The AGNES intervention aims at increasing older peoples' participation in self-selected valued activities.

METHODS

The proposed study is a two-arm single-blinded randomized controlled trial. The intervention group receives individually tailored counselling for an active life (one face-to-face session, four phone calls and supportive written material) and the control group written general health information only. Two hundred older adults aged 75- and 80- year old, with intermediate mobility function and without cognitive impairment, living independently in the municipality of Jyväskylä, Finland, are recruited and randomized with a 1:1 allocation to the intervention and control group. Randomization is computer-generated stratified by sex and age. The primary outcome is active aging and secondary outcomes are well-being, depressive symptoms, quality of life, personal goals, mobility and physical activity. Measures are administered at pre-trial, mid-trial (at 6 months) and post-trial (12 months after baseline).

DISCUSSION

The AGNES intervention study will provide new knowledge on the effects of individualized counselling on active aging and the potential of older people to promote their own well-being.

TRIAL REGISTRATION

The trial is registered at ISRCTN - ISRCTN16172390 : Promoting well-being through active aging.

On the use of a six-level scale for physical activity

The 4-level questionnaire to assess leisure-time physical activity (PA) originally described by Saltin and Grimby has been extended to a 6 (or 7)-level questionnaire, especially for the elderly or other persons with a low level of PA, expanded to include household activities. There are currently two main versions, one used in Swedish, Danish, and Norwegian studies, and one with further modifications used in Finnish studies. In this review, predictive validity for mortality and different aspects of physical performance are demonstrated. In a study regarding concurrent validity in one of the Finnish versions, significant correlations with accelerometer-based PA variables are shown. The scale has been used in a number of studies concerning effects of different types of intervention, such as physical training and increased PA, or to describe the PA level in the studied cohort. In presenting and analyzing the data, different combinations of PA levels have been used. As there are major differences between the versions, validity studies cannot easily be transformed between them. Thus, it is suggested that a common consensus be reached with respect to details of the questionnaire.

A tailored counseling and home-based rehabilitation program to increase physical activity and improve mobility among community-dwelling older people after hospitalization: protocol of a randomized controlled trial

BACKGROUND

Physical activity (PA) decreases during hospitalization. In particular, the amount of PA engaged in by older people who are hospitalized following musculoskeletal injury is likely to be limited for months after discharge home. Given the importance of an active lifestyle for their recovery and the prevention of future adverse outcomes, there is clearly a need for interventions to increase PA. This article describes the protocol of a randomized controlled trial set up to investigate the effects of a physical activity oriented home rehabilitation program (ProPA) on PA and the restoration of mobility in community-dwelling older people.

METHODS

Men and women aged 60 years or older hospitalized due to a musculoskeletal injury or disorder in the back or lower limbs are recruited. After discharge from hospital to home, participants are randomized into a six-month ProPA program or a standard care (control) group. The ProPA program consists of a motivational interview, goal attainment process, guidance for safe walking, a progressive home exercise program and physical activity counseling. In addition, frail participants who are not able to go outdoors alone receive support from volunteers. Primary outcomes are PA measured using a 3-dimentional accelerometer, and mobility assessed by the Short Physical Performance Battery and self-reports. Secondary outcomes are life space mobility, participation restriction, fear of falling, pain, mood, and grip strength. Information on barriers to and enablers of PA participation are also collected. Data on mortality and use of health services are collected from the national register. In this 6-month intervention, all participants are assessed in their homes at baseline and after three and six months, and at 12 months after randomization they will receive a follow-up questionnaire.

DISCUSSION

This study investigates the effects of a rehabilitation program on PA and mobility among older people at risk for increased sedentary time and mobility problems. If positive effects are observed, the program can be considered for incorporation into the health care system and thereby contribute to the rehabilitation of older people who have recently been discharged from hospital.

TRIAL REGISTRATION

ISRCTN13461584 . Registered 27 January 2016.

Physical Activity After a Hip Fracture: Effect of a Multicomponent Home-Based Rehabilitation Program-A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVES

To investigate the effect of a yearlong multicomponent rehabilitation program on the level of physical activity (PA) and the maintenance of the level of PA over 1-year follow-up among older people recovering from a recent hip fracture.

DESIGN

Secondary analysis of a randomized, controlled, parallel-group trial.

SETTING

Home-based rehabilitation; measurements in university laboratory.

PARTICIPANTS

Community-dwelling people (N=81) aged ≥60 years recovering from a hip fracture. Participants were randomly assigned to an intervention (n=40) or a control (n=41) group, on average, 42±23 days after discharge from the hospital.

INTERVENTION

A yearlong intervention included evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacologic pain management, a progressive home exercise program, PA counseling, and standard care.

MAIN OUTCOME MEASURES

The outcome was the level of PA, which was assessed with the questionnaire (a modified Grimby scale) at baseline, and 3, 6, 12, and 24 months after baseline. Three PA categories were defined: inactivity, light PA, and moderate to heavy PA. Physical function was assessed using the Short Physical Performance Battery (SPPB) at baseline. The effects of the intervention were analyzed with generalized estimating equations.

RESULTS

In the intervention group, a significant increase was observed in the level of PA after the intervention (interaction P=.005) and after 1-year follow-up (P=.021) compared with the standard care only. The benefit was particularly evident among the participants with a baseline SPPB score of ≥7 (interaction P<.001).

CONCLUSIONS

The 12-month individualized multicomponent rehabilitation program increased PA among older patients with hip fracture. The increase was found to be maintained at the 1-year follow-up.

Validity of a single question to assess habitual physical activity of community-dwelling older people

The aim is to determine concurrent validity of a single self-report habitual physical activity (PA) question against accelerometer-based PA and mobility variables, and corresponding changes in self-reported PA and mobility. Cross-sectional and longitudinal data of the "Life-space mobility in old age" (LISPE) cohort and its substudy on PA were utilized. At baseline, 848 community-dwelling, 75- to 90-year-old people living independently in central Finland participated in home-based interviews. One and 2 years later, 816 and 761 of them were reassessed by phone, respectively. Tri-axial accelerometer data over 7 days were collected following the baseline assessments in a subsample of 174. Self-reported habitual PA was assessed based on intensity and duration using a single question with seven response options (range: mostly resting to competitive sports). Mobility variables were as follows: life-space mobility, walking difficulty over 500 m, and short physical performance battery. Statistically significant correlations were found between self-reported habitual PA and mobility (Spearman correlation coefficient Rs = 0.40-0.61) and accelerometer-based PA variables [step counts (Rs = 0.49), time in moderate (Rs = 0.49) and low intensity (Rs = 0.40) PA, and time in sedentary behavior (Rs = -0.28)]. A decline in self-reported habitual PA over time was associated with 5-10p decline in life-space mobility (PA improvement with 0-3p increase) and with developing a higher degree of walking difficulty (in 35-44% of participants). In conclusion, based on these results, the self-report question to assess habitual PA is valid and responsive to change and thus useful for epidemiological research in community-dwelling older people, also in follow-up studies.

Home-Based Exercise Supported by General Practitioner Practices: Ineffective in a Sample of Chronically Ill, Mobility-Limited Older Adults (the HOMEfit Randomized Controlled Trial)

OBJECTIVES

To evaluate the effects a home-based exercise program delivered to ill and mobility-limited elderly individuals on physical function, physical activity, quality of life, fall-related self-efficacy, and exercise self-efficacy.

DESIGN

Randomized controlled trial (ISRCTN Registry, Reg.-No. ISRCTN17727272).

SETTING

Fifteen general practitioner (GP) practices and participants' homes.

PARTICIPANTS

Chronically ill and mobility-limited individuals aged 70 and older (N = 209).

INTERVENTIONS

An exercise therapist delivered the experimental intervention-a 12-week multidimensional home-based exercise program integrating behavioral strategies-in individual counseling sessions at the GPs' practices and over the telephone. The control intervention focused on promoting light-intensity activities of daily living. Interventions took place between February 2012 and March 2013.

MEASUREMENTS

The primary outcome was functional lower body strength (chair-rise test). Secondary outcomes were physical function (battery of motor tests), physical activity (step count), health-related quality of life (Medical Outcomes Study 8-item Short-Form Survey), fall-related (Falls Efficacy Scale-International Version), and exercise self-efficacy (Selbstwirksamkeit zur sportlichen Aktivitaet (SSA) scale). Postintervention differences between the groups were tested using analysis of covariance (intention to treat; adjusted for baseline value and GP practice; significance level P ≤ .05).

RESULTS

Participants had a mean age ± standard deviation of 80 ± 5, 74% were female, 87% had three or more chronic diseases, and 54% used a walking aid. The difference (intention to treat; experimental minus control) between adjusted postintervention chair-rise times was -0.1 (95% confidence interval = -1.8-1.7). Differences for all secondary outcomes were also nonsignificant.

CONCLUSION

The program was ineffective in the target population. Possibilities for improving the concept will have to be evaluated.

Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial

OBJECTIVE

To investigate whether a home-based rehabilitation program for community-dwelling older people with recent hip fracture is more effective than standard care in improving mobility recovery and reducing disability.

DESIGN

Randomized, controlled, parallel-group trial.

SETTING

Rehabilitation in participants' homes; measurements in university-based laboratory and local hospital.

PARTICIPANTS

Clinical population of community-dwelling men and women (aged 60+) recovering from hip fracture. Participants were randomly assigned into control (n = 41) or intervention (n = 40) groups on average 42 ± 23 days after discharge home.

INTERVENTION

A yearlong multicomponent home-based rehabilitation aimed at promoting mobility recovery and physical functional capacity after hip fracture. The intervention included evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacological pain management, a progressive home exercise program, physical activity counseling, and standard care.

MEASUREMENTS

Measurements were outlined according to the tiers of the disablement process, with the ability to negotiate stairs as the main outcome. Prefracture ability to negotiate stairs was enquired at the hospital on average 10 ± 5 days after fracture. Subsequently, current perceived ability to negotiate stairs was reported immediately before the intervention (on average 9 weeks after surgery) and 3, 6, and 12 months thereafter. Other measurements included leg extension power deficit (LEP), functional balance (Berg Balance Scale) and lower extremity performance (Short Physical Performance Battery). Effects of the intervention were analyzed with generalized estimation equations and longitudinal repeated measures mixture path models.

RESULTS

The intervention reduced perceived difficulties in negotiating stairs (interaction, group × time P = .001) from prefracture to 12 months compared with the control condition. The mixture path model revealed that less difficulty in negotiating stairs at 6 and 12 months correlated with better functional balance at 3 and 6 months in the intervention group but not controls (group difference P = .007 and P < .001, respectively).

CONCLUSION

The individualized home-based rehabilitation program improved mobility recovery after hip fracture over standard care. To be efficacious in reducing or reversing disability after hip fracture, rehabilitation needs to be individualized, include many components, be progressive, and span a sufficiently long period. Current Controlled Trials (ISRCTN53680197).

Promoting mobility in older people

Out-of-home mobility is necessary for accessing commodities, making use of neighborhood facilities, and participation in meaningful social, cultural, and physical activities. Mobility also promotes healthy aging as it relates to the basic human need of physical movement. Mobility is typically assessed either with standardized performance-based tests or with self-reports of perceived difficulty in carrying out specific mobility tasks. Mobility declines with increasing age, and the most complex and demanding tasks are affected first. Sometimes people cope with declining functional capacity by making changes in their way or frequency of doing these tasks, thus avoiding facing manifest difficulties. From the physiological point of view, walking is an integrated result of the functioning of the musculoskeletal, cardio-respiratory, sensory and neural systems. Studies have shown that interventions aiming to increase muscle strength will also improve mobility. Physical activity counseling, an educational intervention aiming to increase physical activity, may also prevent mobility decline among older people. Sensory deficits, such as poor vision and hearing may increase the risk of mobility decline. Consequently, rehabilitation of sensory functions may prevent falls and decline in mobility. To promote mobility, it is not enough to target only individuals because environmental barriers to mobility may also accelerate mobility decline among older people. Communities need to promote the accessibility of physical environments while also trying to minimize negative or stereotypic attitudes toward the physical activity of older people.

Promoting mobility after hip fracture (ProMo): study protocol and selected baseline results of a year-long randomized controlled trial among community-dwelling older people

Background

To cope at their homes, community-dwelling older people surviving a hip fracture need a sufficient amount of functional ability and mobility. There is a lack of evidence on the best practices supporting recovery after hip fracture. The purpose of this article is to describe the design, intervention and demographic baseline results of a study investigating the effects of a rehabilitation program aiming to restore mobility and functional capacity among community-dwelling participants after hip fracture.

Methods/Design

Population-based sample of over 60-year-old community-dwelling men and women operated for hip fracture (n = 81, mean age 79 years, 78% were women) participated in this study and were randomly allocated into control (Standard Care) and ProMo intervention groups on average 10 weeks post fracture and 6 weeks after discharged to home. Standard Care included written home exercise program with 5-7 exercises for lower limbs. Of all participants, 12 got a referral to physiotherapy. After discharged to home, only 50% adhered to Standard Care. None of the participants were followed-up for Standard Care or mobility recovery. ProMo-intervention included Standard Care and a year-long program including evaluation/modification of environmental hazards, guidance for safe walking, pain management, progressive home exercise program and physical activity counseling. Measurements included a comprehensive battery of laboratory tests and self-report on mobility limitation, disability, physical functional capacity and health as well as assessments for the key prerequisites for mobility, disability and functional capacity. All assessments were performed blinded at the research laboratory. No significant differences were observed between intervention and control groups in any of the demographic variables.

Discussion

Ten weeks post hip fracture only half of the participants were compliant to Standard Care. No follow-up for Standard Care or mobility recovery occurred. There is a need for rehabilitation and follow-up for mobility recovery after hip fracture. However, the effectiveness of the ProMo program can only be assessed at the end of the study.

Trial registration

Current Controlled Trials ISRCTN53680197