Can occupational therapist-led home environmental assessment prevent falls in older people? A modified cohort randomised controlled trial protocol

Undertaking Studies Within A Trial to evaluate recruitment and retention strategies for randomised controlled trials: lessons learnt from the PROMETHEUS research programme

Background

Randomised controlled trials ('trials') are susceptible to poor participant recruitment and retention. Studies Within A Trial are the strongest methods for testing the effectiveness of strategies to improve recruitment and retention. However, relatively few of these have been conducted.

Objectives

PROMoting THE Use of Studies Within A Trial aimed to facilitate at least 25 Studies Within A Trial evaluating recruitment or retention strategies. We share our experience of delivering the PROMoting THE Use of Studies Within A Trial programme, and the lessons learnt for undertaking randomised Studies Within A Trial.

Design

A network of 10 Clinical Trials Units and 1 primary care research centre committed to conducting randomised controlled Studies Within A Trial of recruitment and/or retention strategies was established. Promising recruitment and retention strategies were identified from various sources including Cochrane systematic reviews, the Study Within A Trial Repository, and existing prioritisation exercises, which were reviewed by patient and public members to create an initial priority list of seven recruitment and eight retention interventions. Host trial teams could apply for funding and receive support from the PROMoting THE Use of Studies Within A Trial team to undertake Studies Within A Trial. We also tested the feasibility of undertaking co-ordinated Studies Within A Trial, across multiple host trials simultaneously.

Setting

Clinical trials unit-based trials recruiting or following up participants in any setting in the United Kingdom were eligible.

Participants

Clinical trials unit-based teams undertaking trials in any clinical context in the United Kingdom.

Interventions

Funding of up to £5000 and support from the PROMoting THE Use of Studies Within A Trial team to design, implement and report Studies Within A Trial.

Main outcome measures

Number of host trials funded.

Results

Forty-two Studies Within A Trial were funded (31 host trials), across 12 Clinical Trials Units. The mean cost of a Study Within A Trial was £3535. Twelve Studies Within A Trial tested the same strategy across multiple host trials using a co-ordinated Study Within A Trial design, and four used a factorial design. Two recruitment and five retention strategies were evaluated in more than one host trial. PROMoting THE Use of Studies Within A Trial will add 18% more Studies Within A Trial to the Cochrane systematic review of recruitment strategies, and 79% more Studies Within A Trial to the Cochrane review of retention strategies. For retention, we found that pre-notifying participants by card, letter or e-mail before sending questionnaires was effective, as was the use of pens, and sending personalised text messages to improve questionnaire response. We highlight key lessons learnt to guide others planning Studies Within A Trial, including involving patient and public involvement partners; prioritising and selecting strategies to evaluate and elements to consider when designing a Study Within A Trial; obtaining governance approvals; implementing Studies Within A Trial, including individual and co-ordinated Studies Within A Trials; and reporting Study Within A Trials.

Limitations

The COVID-19 pandemic negatively impacted five Studies Within A Trial, being either delayed (n = 2) or prematurely terminated (n = 3).

Conclusions

PROMoting THE Use of Studies Within A Trial significantly increased the evidence base for recruitment and retention strategies. When provided with both funding and practical support, host trial teams successfully implemented Studies Within A Trial.

Future work

Future research should identify and target gaps in the evidence base, including widening Study Within A Trial uptake, undertaking more complex Studies Within A Trial and translating Study Within A Trial evidence into practice.

Study registration

All Studies Within A Trial in the PROMoting THE Use of Studies Within A Trial programme had to be registered with the Northern Ireland Network for Trials Methodology Research Study Within A Trial Repository.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/55/80) and is published in full in Health Technology Assessment; Vol. 28, No. 2. See the NIHR Funding and Awards website for further award information.

Environmental interventions for preventing falls in older people living in the community

BACKGROUND

Falls and fall-related injuries are common. A third of community-dwelling people aged over 65 years fall each year. Falls can have serious consequences including restricting activity or institutionalisation. This review updates the previous evidence for environmental interventions in fall prevention.

OBJECTIVES

To assess the effects (benefits and harms) of environmental interventions (such as fall-hazard reduction, assistive technology, home modifications, and education) for preventing falls in older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, other databases, trial registers, and reference lists of systematic reviews to January 2021. We contacted researchers in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials evaluating the effects of environmental interventions (such as reduction of fall hazards in the home, assistive devices) on falls in community-residing people aged 60 years and over.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.

MAIN RESULTS

We included 22 studies from 10 countries involving 8463 community-residing older people. Participants were on average 78 years old, and 65% were women. For fall outcomes, five studies had high risk of bias and most studies had unclear risk of bias for one or more risk of bias domains. For other outcomes (e.g. fractures), most studies were at high risk of detection bias. We downgraded the certainty of the evidence for high risk of bias, imprecision, and/or inconsistency.  Home fall-hazard reduction (14 studies, 5830 participants) These interventions aim to reduce falls by assessing fall hazards and making environmental safety adaptations (e.g. non-slip strips on steps) or behavioural strategies (e.g. avoiding clutter).  Home fall-hazard interventions probably reduce the overall rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.61 to 0.91; 12 studies, 5293 participants; moderate-certainty evidence); based on a control group risk of 1319 falls per 1000 people a year, this is 343 (95% CI 118 to 514) fewer falls. However, these interventions were more effective in people who are selected for higher risk of falling, with a reduction of 38% (RaR 0.62, 95% CI 0.56 to 0.70; 9 studies, 1513 participants; 702 (95% CI 554 to 812) fewer falls based on a control risk of 1847 falls per 1000 people; high-certainty evidence). We found no evidence of a reduction in rate of falls when people were not selected for fall risk (RaR 1.05, 95% CI 0.96 to 1.16; 6 studies, 3780 participants; high-certainty evidence). Findings were similar for the number of people experiencing one or more falls. These interventions probably reduce the overall risk by 11% (risk ratio (RR) 0.89, 95% CI 0.82 to 0.97; 12 studies, 5253 participants; moderate-certainty evidence); based on a risk of 519 per 1000 people per year, this is 57 (95% CI 15 to 93) fewer fallers. However, for people at higher risk of falling, we found a 26% decrease in risk (RR 0.74, 95% CI 0.65 to 0.85; 9 studies, 1473 participants), but no decrease for unselected populations (RR 0.99, 95% CI 0.92 to 1.07; 6 studies, 3780 participants) (high-certainty evidence). These interventions probably make little or no important difference to health-related quality of life (HRQoL) (standardised mean difference 0.09, 95% CI -0.10 to 0.27; 5 studies, 1848 participants; moderate-certainty evidence). They may make little or no difference to the risk of fall-related fractures (RR 1.00, 95% 0.98 to 1.02; 2 studies, 1668 participants), fall-related hospitalisations (RR 0.96, 95% CI 0.87 to 1.06; 3 studies, 325 participants), or in the rate of falls requiring medical attention (RaR 0.91, 95% CI 0.58 to 1.43; 3 studies, 946 participants) (low-certainty evidence). The evidence for number of fallers requiring medical attention was unclear (2 studies, 216 participants; very low-certainty evidence). Two studies reported no adverse events. Assistive technology Vision improvement interventions may make little or no difference to the rate of falls (RaR 1.12, 95% CI 0.84 to 1.50; 3 studies, 1489 participants) or people experiencing one or more falls (RR 1.09, 95% CI 0.79 to 1.50) (low-certainty evidence). We are unsure of the evidence for fall-related fractures (2 studies, 976 participants) and falls requiring medical attention (1 study, 276 participants) because the certainty of the evidence is very low. There may be little or no difference in HRQoL (mean difference 0.40, 95% CI -1.12 to 1.92) or adverse events (falls while switching glasses; RR 1.00, 95% CI 0.98 to 1.02) (1 study, 597 participants; low-certainty evidence). Results for other assistive technology - footwear and foot devices, and self-care and assistive devices (5 studies, 651 participants) - were not pooled due to the diversity of interventions and contexts.  Education  We are uncertain whether an education intervention to reduce home fall hazards reduces the rate of falls or the number of people experiencing one or more falls (1 study; very low-certainty evidence). These interventions may make little or no difference to the risk of fall-related fractures (RR 1.02, 95% CI 0.96 to 1.08; 1 study, 110 participants; low-certainty evidence).  Home modifications We found no trials of home modifications that measured falls as an outcome for task enablement and functional independence.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that home fall-hazard interventions are effective in reducing the rate of falls and the number of fallers when targeted to people at higher risk of falling, such as having had a fall in the past year and recently hospitalised or needing support with daily activities. There was evidence of no effect when interventions were targeted to people not selected for risk of falling. Further research is needed to examine the impact of intervention components, the effect of awareness raising, and participant-interventionist engagement on decision-making and adherence.  Vision improvement interventions may or may not impact the rate of falls. Further research is needed to answer clinical questions such as whether people should be given advice or take additional precautions when changing eye prescriptions, or whether the intervention is more effective when targeting people at higher risk of falls. There was insufficient evidence to determine whether education interventions impact falls.

Ageing in place - exploring the safety of the environment of Slovenian older adults

Objective

The importance of subjective and objective living environment was investigated.

Methods

A new questionnaire was developed, validated and distributed to community-dwelling adults in various Slovenian counties. Data were analysed using descriptive statistics and t-tests in SPSS Statistics 24. Older adults (N = 358), 33% men and 67% women, mean age 74.3 years, participated in the cross-sectional study.

Results

Statistically significant differences (at 5% significance level) in subjective opinions of older adults regarding views on appropriate design of the living environment between the group with and without risk factors exist only for the statement that a thermostat to regulate room temperature should be placed in a visible and accessible location (p = 0.014).

Conclusion

The living environment has some risk factors, but they are not statistically significant between groups. The results may prompt occupational therapists to develop innovative strategies to facilitate occupational participation of users, increase participation in preventive services and obtain policy support.

Reliability of HOME FAST BRAZIL-Self-Reported Version for Community-Dwelling Older Adults

Objective: Verify the intra- and inter-rater reliability of the HOME FAST BRAZIL—Self-reported version and correlate household environmental risks with the history of falls by community-dwelling older adults.

Method: Cross sectional study with 50 community-dwelling older adults who were screened by the cut-off point of the Mini Mental State Exam and replied to the HOME FAST BRAZIL—Self-reported version using two evaluators, on three occasions. The reliability analysis was determined by the Intra-class Correlation Coefficient (ICC), considering ICC > 0.70 as adequate. To test the correlations, the Spearman test was used.

Results: The mean age of the participants was 73.2 ± 5.8 years. The inter- rater reliability of HOME FAST BRAZIL—Self-reported version was ICC 0.83 (IC95%, 0.70–0.90) and the Intra- reliability ICC 0.85 (IC95%, 0.74–0.91). A risk of falls was verified in 88% of the sample and four environmental risks presented significant correlations with the history of falls.

Conclusions: The HOME FAST BRAZIL—Self-reported version presented adequate reliability for the evaluation of household environmental risks for community-dwelling older adults. Risks such as inadequate armchairs/ sofas, the absence of anti-slip mats in the shower recess, the presence of pets and inadequate beds require attention in the evaluation of household risks, due to their correlation with the occurrence of falls.

Including a pen and/or cover letter, containing social incentive text, had no effect on questionnaire response rate: a factorial randomised controlled Study within a Trial

Background: Postal questionnaires are frequently used in randomised controlled trials to collect outcome data on participants; however, poor response can introduce bias, affect generalisability and validity, and reduce statistical power. The objective of this study was to assess whether a pen and/or social incentive text cover letter sent with a postal follow-up questionnaire increased response rates in a trial.

Method: A two-by-two factorial randomised controlled trial was embedded within the OTIS host trial. Participants due their 12-month (final) follow-up questionnaire were randomised to be sent: a pen; a social incentive text cover letter; both; or neither. The primary outcome measure was the proportion of participants in each group who returned the questionnaire. Secondary outcomes were: time to return, completeness of the questionnaire, necessity of a reminder letter, and the cost effectiveness.

Results: The overall 12-month questionnaire response rate was 721 out of 755 (95.5%). Neither the pen nor social incentive cover letter had a statistically significant effect on response rate: pen 95.2% vs. no pen 95.8%, adjusted OR 0.90 (95% CI 0.45 to 1.80; p=0.77); social incentive cover letter 95.2% vs. no social incentive cover letter 95.8%, adjusted OR 0.84 (95% CI 0.42 to 1.69, p=0.63). No statistically significant differences were observed between either of the intervention groups on time to response, need for a reminder or completeness. Therefore, neither intervention was cost-effective.

Conclusions: We found no evidence of a difference in response rates associated with the inclusion of a pen and/or social incentive cover letter with the final follow-up postal questionnaire of the host trial. However, when these results are combined with previous SWATs, the meta-analysis evidence remains that including a pen increases response rates. The social incentive cover letter warrants further investigation to determine effectiveness.

Trial registration: ISRCTN22202133 (21st June 2020).

Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: the OTIS RCT

BACKGROUND

Falls and fall-related fractures are highly prevalent among older people and are a major contributor to morbidity and costs to individuals and society. Only one small pilot trial has evaluated the effectiveness of a home hazard assessment and environmental modification in the UK. This trial reported a reduction in falls as a secondary outcome, and no economic evaluation was undertaken. Therefore, the results need to be confirmed and a cost-effectiveness analysis needs to be undertaken.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of a home hazard assessment and environmental modification delivered by occupational therapists for preventing falls among community-dwelling people aged ≥ 65 years who are at risk of falling, relative to usual care.

DESIGN

This was a pragmatic, multicentre, modified cohort randomised controlled trial with an economic evaluation and a qualitative study.

SETTING

Eight NHS trusts in primary and secondary care in England.

PARTICIPANTS

In total, 1331 participants were randomised (intervention group, n = 430; usual-care group, n = 901) via a secure, remote service. Blinding was not possible.

INTERVENTIONS

All participants received a falls prevention leaflet and routine care from their general practitioner. The intervention group were additionally offered one home environmental assessment and modifications recommended or provided to identify and manage personal fall-related hazards, delivered by an occupational therapist.

MAIN OUTCOME MEASURES

The primary outcome was the number of falls per participant during the 12 months from randomisation. The secondary outcomes were the proportion of fallers and multiple fallers, time to fall, fear of falling, fracture rate, health-related quality of life and cost-effectiveness.

RESULTS

The primary analysis included all 1331 randomised participants and indicated weak evidence of a difference in fall rate between the two groups, with an increase in the intervention group relative to usual care (adjusted incidence rate ratio 1.17, 95% confidence interval 0.99 to 1.38; p = 0.07). A similar proportion of participants in the intervention group (57.0%) and the usual-care group (56.2%) reported at least one fall over 12 months. There were no differences in any of the secondary outcomes. The base-case cost-effectiveness analysis from an NHS and Personal Social Services perspective found that, on average per participant, the intervention was associated with additional costs (£18.78, 95% confidence interval £16.33 to £21.24), but was less effective (mean quality-adjusted life-year loss -0.0042, 95% confidence interval -0.0041 to -0.0043). Sensitivity analyses demonstrated uncertainty in these findings. No serious, related adverse events were reported. The intervention was largely delivered as intended, but recommendations were followed to a varying degree.

LIMITATIONS

Outcome data were self-reported by participants, which may have led to inaccuracies in the reported falls data.

CONCLUSIONS

We found no evidence that an occupational therapist-delivered home assessment and modification reduced falls in this population of community-dwelling participants aged ≥ 65 years deemed at risk of falling. The intervention was more expensive and less effective than usual care, and therefore it does not provide a cost-effective alternative to usual care.

FUTURE WORK

An evaluation of falls prevention advice in a higher-risk population, perhaps those previously hospitalised for a fall, or given by other professional staff could be justified.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22202133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 46. See the NIHR Journals Library website for further project information.

Smart homes for the older population: particularly important during the COVID-19 outbreak

Osteoporosis, one of the leading causes of disability in older adults, significantly reduces the quality of life and leads to loss of independence. Dynamic development of “smart” solutions based on artificial intelligence more and more commonly applied in older people’s houses may be an answer to the above issues.

The aim of this study is to present selected “smart home” solutions for the diagnosis and prevention of falls in the older population through a literature review. The conducted meta-analysis based on a review of the scientific literature available in English and Polish in the Medline/PubMed, Embase, Scopus, and GBL databases was undertaken from 01.01.2015 to 01.10.2020 with the string search method using key words.

According to the authors of this study, the development of new technology based on artificial intelligence allows older people to live independently, which contributes to a higher level of life satisfaction and quality.

The effectiveness of a recurrent fall prevention program applied to elderly people undergoing fracture treatment

BACKGROUND

Worldwide 30-40% of people aged of 65 and over fall each year. It is important to develop preventive interventions for falls in the elderly to prevent injuries leading to mortality and morbidity.

OBJECTIVES

This study evaluated the effectiveness of a recurrent fall prevention program in elderly individuals undergoing fracture treatment.

METHODS

A pretest-posttest intervention study. A recurrent fall prevention program including assessment of fall risk factors, education on falls and home modifications was developed for elderly people undergoing fracture treatment for 52 patients.

RESULTS

In the first evaluation before the delivery of the recurrent fall prevention program, the number of risk factors was 17.63 ± 3.40 as mean ± standart deviation. Following implementation of the fall prevention program, the number of risk factors decreased to 15.73 ± 3.19 in the first follow-up and decreased to 14.92 ± 3.06 in the second follow-up. Knowledge scores increased to 6.09 ± 1.65 in the first follow-up and to 6.71 ± 1.53 in the second follow-up, while it was 5.50 ± 1.54 in first evaluation. The differences between follow-ups were statistically significant. During the 3-month study period, 15.4% of participants experienced fall.

CONCLUSION

The recurrent fall prevention program was effective in reducing fall-related risk factors and increase fall knowledge. Health care professionals should assess older people for fall risk factors and increase their awareness for falls.

An evaluation of a personalised text message reminder compared to a standard text message on postal questionnaire response rates: an embedded randomised controlled trial

Background: Research outcome data is commonly collected using postal questionnaires; however, poor response can introduce bias and reduce statistical power. Text messaging is simple, cost-effective, and can be customised to the individual. Personalised, reminder text messages may improve response rates.

Methods: A two-arm, parallel group ‘Study within a Trial’ (SWAT) was embedded within the Occupational Therapist Intervention Study (OTIS), a randomised controlled trial of a home assessment for falls prevention in older people.  OTIS participants who provided a mobile phone number were randomly allocated (1:1) to receive either a personalised text message (Title, Surname, plus York Trials Unit (YTU) text) or the standard YTU text alone, prior to receiving their four-month post-randomisation follow-up postal questionnaire. The primary outcome measure was the proportion of participants who returned the questionnaire. Secondary outcomes were: time to response, completeness of response, requirement of a reminder letter, and cost-effectiveness. Binary data were compared using logistic regression and time to response by Cox proportional hazards regression.

Results: A total of 403 participants were randomised: 201 to the personalised text and 202 to the standard text.  Of the 283 participants included in the final analysis, 278 (98.2%) returned their questionnaire; 136 (97.8%) for the personalised text versus 142 (98.6%) for the standard text (adjusted odds ratio 0.64, 95% CI 0.10 to 3.88, p=0.63).  The median time to response was nine days in both groups.  In total, 271 (97.5%) participants returned a complete questionnaire; 133 (97.8%) in the personalised text versus 138 (97.2%) for the standard text.  In total, 21 reminder letters were sent. The additional cost of personalised text messages was £0.04 per participant retained.

Conclusions: Personalised texts were not superior to standard texts in any outcome assessed in our study. Further SWATs are needed to perform a meta-analysis and obtain more evidence.

Registration: ISRCTN22202133; SWAT 35.

A Review of the Development and Application of Generic Preference-Based Instruments with the Older Population

Older people (aged 65 years and over) are the fastest growing age cohort in the majority of developed countries, and the proportion of individuals defined as the oldest old (aged 80 years and over) living with physical frailty and cognitive impairment is rising. These population changes put increasing pressure on health and aged care services, thus it is important to assess the cost effectiveness of interventions targeted for older people across health and aged care sectors to identify interventions with the strongest capacity to enhance older peoples' quality of life and provide value for money. Cost-utility analysis (CUA) is a form of economic evaluation that typically uses preference-based instruments to measure and value health-related quality of life for the calculation of quality-adjusted life-years (QALYS) to enable comparisons of the cost effectiveness of different interventions. A variety of generic preference-based instruments have been used to measure older people's quality of life, including the Adult Social Care Outcomes Toolkit (ASCOT); Health Utility Index Mark 2 (HUI2); Health Utility Index Mark 3 (HUI3); Short-Form-6 Dimensions (SF-6D); Assessment of Quality of Life-6 dimensions (AQoL-6D); Assessment of Quality of Life-8 dimensions (AQoL-8D); Quality of Wellbeing Scale-Self-Administered (QWB-SA); 15 Dimensions (15D); EuroQol-5 dimensions (EQ-5D); and an older person specific preference-based instrument-the Investigating Choice Experiments Capability Measure for older people (ICECAP-O). This article reviews the development and application of these instruments within the older population and discusses the issues surrounding their use with this population. Areas for further research relating to the development and application of generic preference-based instruments with populations of older people are also highlighted.

Does handwriting the name of a potential trial participant on an invitation letter improve recruitment rates? A randomised controlled study within a trial

Background: Randomised controlled trials (RCTs) often fail to recruit to target, resulting in a lack of generalisability of findings. A wide range of strategies for potentially increasing recruitment have been identified; however, their effectiveness has not been established. The aim of this study within a trial (SWAT) was to evaluate the effectiveness of handwritten personalisation of an invitation letter as part of a trial recruitment pack on recruitment to a host RCT. Methods: A pragmatic, two-armed RCT was conducted, embedded within an existing falls prevention trial (OTIS) in men and women aged 65 years and over living in the community. Participants were randomised 1:1 to receive an OTIS recruitment pack containing an invitation letter on which their name was handwritten (intervention group), or one on which it was printed (control group). The primary outcome was randomisation into the host trial.  Secondary outcomes related to trial eligibility and retention.  Analyses were via logistic regression and Cox Proportional Hazards regression. Results: Of the 317 SWAT participants, 12 (3.8%) were randomised into the OTIS trial: 3 (handwritten: 3/159 [1.9%]; printed: 9/158 [5.7%]; difference -3.8%, 95% CI -8.0% to 0.4%). There was weak evidence, against the intervention, of a difference in the likelihood of participants being randomised into the host trial between the two groups (OR 0.32, 95% CI 0.08 to 1.20, p=0.09). There were no statistically significant differences between the intervention and control groups on any of the secondary outcomes. Conclusions: There was no evidence that personalisation of invitation letters improved recruitment to the OTIS trial. However, due to the small sample size, the results should be interpreted with caution. These findings need to be replicated across larger studies and wider populations. Registration: ISRCTN22202133.

Using pens as an incentive for trial recruitment of older adults: An embedded randomised controlled trial

Background: Meeting recruitment targets for randomised controlled trials is challenging.  This trial evaluated the effectiveness of including a pen within the trial invitation pack on the recruitment of older adults into a randomised controlled trial. Methods: This trial was embedded within the Occupational Therapist Intervention Study, a falls-prevention randomised controlled trial.  Potential participants (n = 1862), who were posted an invitation pack from two General Practitioner practices, were randomised to either not receive a pen (n = 1295) or receive a pen (n = 648) with their invitation pack, using a 2:1 ratio.  The primary outcome was the likelihood of being randomised, and therefore fully recruited, to the host trial.  To be randomised to the host trial, participants had to: return a consent form and screening form; be eligible on their screening form; and return a baseline questionnaire and a monthly falls calendar.  Secondary outcomes were: the likelihood of returning (and time to return) a screening form; being eligible for the host trial; and remaining in the trial for at least 3 months. Results: The likelihood of being randomised to the host trial did not differ between the pen group (4.5%) and no pen group (4.3%; odds ratio 1.04; 95% confidence interval: 0.65 to 1.67; p = 0.86).  There were marginal differences in secondary outcomes in favour of the pen group, particularly in screening form return rates, though these differences were not statistically significant. Conclusion: Pens may not be an effective incentive for the recruitment of older adults into randomised controlled trials, though future trials are required. Registration: ISRCTN22202133; SWAT 37.