Exercise referral schemes enhanced by self-management strategies to reduce sedentary behaviour and increase physical activity among community-dwelling older adults from four European countries: protocol for the process evaluation of the SITLESS randomised controlled trial

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.

Dynamic associations between frailty and cognition over 4 years: A population-based study on adults aged ≥50 from 12 European countries

PURPOSE

This study aimed (1) to investigate autoregressive and cross-lagged associations between frailty and cognition over 4 years in a large sample of European citizens aged ≥50 years, (2) to examine the 4-year temporal associations' differences between sex and between active and inactive physical behaviour, and (3) to explore in the years 2011, 2013, and 2015 associations between cognitive performance and the pre-frailty and frailty conditions.

MATERIALS AND METHODS

This longitudinal analysis was conducted with 20,857 individuals (11,540 women) from 12 countries aged ≥50 years who responded to waves 4, 5, and 6 of the SHARE project. The variables analysed were frailty (SHARE-FI) and a general cognition index (Cogindex) calculated for each wave from verbal fluency, immediate recall, and delayed recall.

RESULTS

A greater propensity for cognitive impairment was found in women, as well as in pre-frail and frail individuals. There were no significant differences between the sexes for the autoregressive effect of frailty and Cogindex over 4 years. On the other hand, sedentary and active individuals differed in frailty between Time 1-2. Cross-lagged analyses indicated a significant difference for the sexes between frailty and Cogindex Time 1-3 and between Cogindex and frailty of Time 2-3. Sedentary and active differed significantly in the path of frailty on Cogindex between Time 2-3.

CONCLUSION

Health policies should increase surveillance of frailty, cognition, and level of physical activity in the older European population, with a special focus on women.

The role of self-regulation strategies in physical activity behavior change: results from an exercise prescription program at a Federally Qualified Health Center

Physical activity (PA) improves quality of life and prevents chronic disease, yet many adults are inactive. Planning with health care providers in the form of exercise "prescriptions" may increase PA, but the role of individual psychosocial factors within exercise prescription programs is not well understood. Therefore, the purpose of this study is to describe the role of self-regulation strategies (e.g., goal setting, self-monitoring, reinforcements) in PA behavior change within the context of an exercise prescription program. Patients at a large, Federally Qualified Health Center with an on-site exercise facility (ie, "Wellness Center") referral were eligible to exercise with a personal fitness advisor. Self-reported PA and use of 15 self-regulation strategies were measured via survey at two time points and merged with electronic health records and attendance data. Patients (n = 151) were, on average, 50.3 ± 13.3 years and mostly female (76.8%). Almost one-third (30.5%) were Hispanic/Latino, 48.3% were non-Hispanic Black, and 20.5% were non-Hispanic white. Participants completed 10.7 ± 12.0 in-person exercise sessions with a fitness advisor. Between baseline and follow-up, the self-regulation strategies that had the largest change in frequency over time were keeping track of PA (p < 0.001), thinking about surroundings (p < 0.001), rewarding yourself for PA (p < 0.001), making PA more enjoyable (p < 0.001), setting goals (p < 0.001), and trying different kinds of PA (p < 0.001). Among exercise prescription program participants, the total self-regulation strategies score was significantly associated with physical activity at follow-up (p = 0.04). Leveraging self-regulatory skill-building activities within the context of exercise prescription programs in clinical settings may provide a personalized and multicomponent approach to PA promotion. Self-regulation strategy training for fitness advisors and/or health care providers has great potential for supporting long-term health behaviors like PA for managing chronic disease among underserved patients.

Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement

Background: Fatigue is the most common symptom among cancer survivors. Cancer-related fatigue (CRF) may occur at any point in the cancer care continuum. Multiple factors contribute to CRF development and severity, including cancer type, treatments, presence of other symptoms, comorbidities, and medication side effects. Clinically, increasing physical activity, enhancing sleep quality, and recognizing sleep disorders are integral to managing CRF. Unfortunately, CRF is infrequently recognized, evaluated, or treated in lung cancer survivors despite more frequent and severe symptoms than in other cancers. Therefore, increased awareness and understanding of CRF are needed to improve health-related quality of life in lung cancer survivors. Objectives: 1) To identify and prioritize knowledge and research gaps and 2) to develop and prioritize research questions to evaluate mechanistic, diagnostic, and therapeutic approaches to CRF among lung cancer survivors. Methods: We convened a multidisciplinary panel to review the available literature on CRF, focusing on the impacts of physical activity, rehabilitation, and sleep disturbances in lung cancer. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in the 1) detection and diagnostic evaluation of CRF in lung cancer survivors; 2) timing, goals, and implementation of physical activity and rehabilitation; and 3) evaluation and treatment of sleep disturbances and disorders to reduce CRF. Finally, we present the panel's initial 32 research questions and seven final prioritized questions. Conclusions: This statement offers a prioritized research agenda to 1) advance clinical and research efforts and 2) increase awareness of CRF in lung cancer survivors.

Do skeletal muscle composition and gene expression as well as acute exercise-induced serum adaptations in older adults depend on fitness status?

Background

Inactive physical behavior among the elderly is one risk factor for cardiovascular disease, immobility and increased all-cause mortality. We aimed to answer the question whether or not circulating and skeletal muscle biomarkers are differentially expressed depending on fitness status in a group of elderly individuals.

Methods

Twenty-eight elderly individuals (73.36 ± 5.46 years) participated in this exploratory study after participating as part of the multinational SITLESS-clinical trial (implementation of self-management and exercise programs over 16 weeks). A cardiopulmonary exercise test (CPX) and resting skeletal muscle biopsy were performed to determine individual physiological performance capacity. Participants were categorized into a high physical fitness group (HPF) and a low physical fitness group (LPF) depending on peak oxygen uptake (VO₂peak). Serum blood samples were taken before (pre) and after (post) CPX and were examined regarding serum BDNF, HSP70, Kynurenine, Irisin and Il-6 concentrations. Skeletal muscle tissue was analyzed by silver staining to determine the myosin heavy chain (MyHC) composition and selected genes by qRT-PCR.

Results

HPF showed lower body weight and body fat, while skeletal muscle mass and oxygen uptake at the first ventilatory threshold (VO₂T1) did not differ between groups. There were positive associations between VO₂peak and VO₂VT1 in HPF and LPF. MyHC isoform quantification revealed no differences between groups. qRT-PCR showed higher expression of BDNF and BRCA1 in LPF skeletal muscle while there were no differences in other examined genes regarding energy metabolism. Basal serum concentrations of Irisin were higher in HPF compared to LPF with a trend towards higher values in BDNF and HSP70 in HPF. Increases in Il-6 in both groups were observed post.

Conclusions

Although no association between muscle composition/VO₂peak with fitness status in older people was detected, higher basal Irisin serum levels in HPF revealed slightly beneficial molecular serum and muscle adaptations.

Trial registration

ClinicalTrials.gov, NCT02629666. Registered 19 November 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02666-0.

Older Adults' Experiences of a Physical Activity and Sedentary Behaviour Intervention: A Nested Qualitative Study in the SITLESS Multi-Country Randomised Clinical Trial

Background: The SITLESS programme comprises exercise referral schemes and self-management strategies and has been evaluated in a trial in Denmark, Spain, Germany and Northern Ireland. The aim of this qualitative study was to understand the implementation and contextual aspects of the intervention in relation to the mechanisms of impact and to explore the perceived effects. Methods: Qualitative methodologies were nested in the SITLESS trial including 71 individual interviews and 12 focus groups targeting intervention and control group participants from postintervention to 18-month follow-up in all intervention sites based on a semi-structured topic guide. Results: Overarching themes were identified under the framework categories of context, implementation, mechanisms of impact and perceived effects. The findings highlight the perceived barriers and facilitators to older adults’ engagement in exercise referral schemes. Social interaction and enjoyment through the group-based programmes are key components to promote adherence and encourage the maintenance of targeted behaviours through peer support and connectedness. Exit strategies and signposting to relevant classes and facilities enabled the maintenance of positive lifestyle behaviours. Conclusions: When designing and implementing interventions, key components enhancing social interaction, enjoyment and continuity should be in place in order to successfully promote sustained behaviour change.

A Prescription for Wellness: Exercise Referrals at a Federally Qualified Health Center

Introduction/Objectives: Physical activity (PA) improves quality of life and prevents chronic disease, but many adults are inactive. Planning with a health care provider in the form of an exercise "prescription" or referral may increase PA, but determinants of referral utilization are not well understood among underserved populations. This study examined sociodemographic and theory-based psychosocial determinants of exercise referral program utilization. Methods: Patients at a large, federally qualified health center with an on-site exercise facility (ie, "Wellness Center") referral were eligible to exercise with a personal fitness advisor. Self-reported PA behavior, self-efficacy, and self-regulation strategies were measured via survey and merged with electronic health records and attendance data. Negative binomial regression was used to estimate the rate of Wellness Center utilization. Results: Patients with exercise referrals (n = 1136) were, on average, 45.6 ± 14.6 years, 78.8% female, and 78.0% Hispanic/Latino or non-Hispanic Black. Approximately half (593/1136; 52.2%) initiated exercise at the Wellness Center; initiators completed 8.8 ± 12.4 visits during follow-up. Older age was associated with higher utilization (P < .001) and patients meeting PA recommendations had lower utilization than patients not meeting recommendations (incident rate ratio = 0.72, 95% CI 0.53-0.97; P = .03). Baseline self-efficacy (P < .001) and self-regulation strategies (P = .03) were significantly associated with follow-up PA, even after adjusting for baseline PA. Conclusions: In this racially/ethnically diverse patient population, older and less active patients at baseline had higher program utilization. Patients with higher self-efficacy and self-regulation strategies reported higher PA over time. Community health centers have a unique opportunity to support PA through exercise referral programs to public health priority populations.