Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions

Psychological and educational interventions for preventing falls in older people living in the community

BACKGROUND

Older adults are at increased risk of both falls and fall-related injuries. Falls have multiple causes and many interventions exist to try and prevent them, including educational and psychological interventions. Educational interventions aim to increase older people's understanding of what they can do to prevent falls and psychological interventions can aim to improve confidence/motivation to engage in activities that may prevent falls. This review is an update of previous evidence to focus on educational and psychological interventions for falls prevention in community-dwelling older people.

OBJECTIVES

To assess the benefits and harms of psychological interventions (such as cognitive behavioural therapy; with or without an education component) and educational interventions for preventing falls in older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two trials registries to June 2023. We also screened reference lists and conducted forward-citation searching.

SELECTION CRITERIA

We included randomised controlled trials of community-dwelling people aged 60 years and older exploring the effectiveness of psychological interventions (such as cognitive behavioural therapy) or educational interventions (or both) aiming to prevent falls.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. We also explored: number of people falling; people with fall-related fractures; people with falls that required medical attention; people with fall-related hospital admission; fall-related psychological outcomes (i.e. concerns about falling); health-related quality of life; and adverse events.

MAIN RESULTS

We included 37 studies (six on cognitive behavioural interventions; three on motivational interviewing; three on other psychological interventions; nine on multifactorial (personalised) education; 12 on multiple topic education; two on single topic education; one with unclear education type; and one psychological plus educational intervention). Studies randomised 17,478 participants (71% women; mean age 73 years). Most studies were at high or unclear risk of bias for one or more domains. Cognitive behavioural interventions Cognitive behavioural interventions make little to no difference to the number of fallers (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.82 to 1.02; 4 studies, 1286 participants; low-certainty evidence), and there was a slight reduction in concerns about falling (standardised mean difference (SMD) -0.30, 95% CI -0.42 to -0.19; 3 studies, 1132 participants; low-certainty evidence). The evidence is very uncertain or missing about the effect of cognitive behavioural interventions on other outcomes. Motivational interviewing The evidence is very uncertain about the effect of motivational interviewing on rate of falls, number of fallers, and fall-related psychological outcomes. No evidence is available on the effects of motivational interviewing on people experiencing fall-related fractures, falls requiring medical attention, fall-related hospital admission, or adverse events. Other psychological interventions The evidence is very uncertain about the effect of health coaching on rate of falls, number of fallers, people sustaining a fall-related fracture, or fall-related hospital admission; the effect of other psychological interventions on these outcomes was not measured. The evidence is very uncertain about the effect of health coaching, guided imagery, and mental practice on fall-related psychological outcomes. The effect of other psychological interventions on falls needing medical attention or adverse events was not measured. Multifactorial education Multifactorial (personalised) education makes little to no difference to the rate of falls (rate ratio 0.95, 95% CI 0.77 to 1.17; 2 studies, 777 participants; low-certainty evidence). The effect of multifactorial education on people experiencing fall-related fractures was very imprecise (RR 0.66, 95% CI 0.29 to 1.48; 2 studies, 510 participants; low-certainty evidence), and the evidence is very uncertain about its effect on the number of fallers. There was no evidence for other outcomes. Multiple component education Multiple component education may improve fall-related psychological outcomes (MD -2.94, 95% CI -4.41 to -1.48; 1 study, 459 participants; low-certainty evidence). However, the evidence is very uncertain about its effect on all other outcomes. Single topic education The evidence is very uncertain about the effect of single-topic education on rate of falls, number of fallers, and people experiencing fall-related fractures. There was no evidence for other outcomes. Psychological plus educational interventions Motivational interviewing/coaching combined with multifactorial (personalised) education likely reduces the rate of falls (although the size of this effect is not clear; rate ratio 0.65, 95% CI 0.43 to 0.99; 1 study, 430 participants; moderate-certainty evidence), but makes little to no difference to the number of fallers (RR 0.93, 95% CI 0.76 to 1.13; 1 study, 430 participants; high-certainty evidence). It probably makes little to no difference to falls-related psychological outcomes (MD -0.70, 95% CI -1.81 to 0.41; 1 study, 353 participants; moderate-certainty evidence). There were no adverse events detected (1 study, 430 participants; moderate-certainty evidence). There was no evidence for psychological plus educational intervention on other outcomes.

AUTHORS' CONCLUSIONS

The evidence suggests that a combined psychological and educational intervention likely reduces the rate of falls (but not fallers), without affecting adverse events. Overall, the evidence for individual psychological interventions or delivering education alone is of low or very-low certainty; future research may change our confidence and understanding of the effects. Cognitive behavioural interventions may improve concerns about falling slightly, but this may not help reduce the number of people who fall. Certain types of education (i.e. multiple component education) may also help reduce concerns about falling, but not necessarily reduce the number of falls. Future research should adhere to reporting standards for describing the interventions used and explore how these interventions may work, to better understand what could best work for whom in what situation. There is a particular dearth of evidence for low- to middle-income countries.

Effects of a Multifactorial Program with Case Management for Falls Prevention on Functional Outcomes in Community-Dwelling Older People: A Randomized Clinical Study

Falls are among the top 10 causes of years lived with disability in people aged 75 and over. Preventive programs like case management (CM) are crucial.

OBJECTIVES

To evaluate the effects of a multifactorial fall prevention program based on CM on physical performance, the presence of pain, and the risk of falls and fractures in older people who have suffered falls.

METHODS

This randomized, single-blind clinical trial with parallel groups, Intervention Group (IG) and Control Group (CG), was composed of 55 older people with a history of falling, living in the community. All participants underwent an initial assessment via video call (containing anamnesis, timed up-and-go test, falls risk score, short physical performance battery, and clinical frax). The IG underwent CM, the physical exercise protocol, and the cognitive stimulation protocol. The CG was monitored through telephone calls and received general health and fall guidance.

RESULTS

No significant results were found in the physical capacity, the presence of pain, the risk of falls, or the fractures between the Intervention and Control Groups and between assessments.

CONCLUSION

This program was not effective in improving functional performance, but it was important for characterizing pain and the probability of fracture in the next 10 years in this population.

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.

Effects of a 12-week intrinsic foot muscle strengthening training (STIFF) on gait in older adults: a parallel randomized controlled trial protocol

BACKGROUND

Falling is highly prevalent among older adults and has serious impact. Age-induced mobility impairments, such as gait modifications, are strongly associated with increased fall risk. Among fall prevention interventions, those including exercises are most effective. However, there is an urgent need to further improve these kinds of interventions. Strengthening the plantar intrinsic foot muscles might benefit mobility in older adults, which may contribute to the reduction of fall risk. The aim of this paper is to provide a protocol to investigate the effect of a plantar intrinsic foot muscle strengthening training versus no training on gait and intrinsic foot muscle function in older adults who are involved in a functional exercise program.

METHODS

For this assessor-blinded RCT, older adults (> 65 years) are recruited who are involved in a group-based functional exercise program. Eligibility criteria include: being able to ambulate 10 m barefoot without using a walking aid and reporting to have either fear of falling or experienced a fall in the previous 12 months or have difficulties with mobility, gait, or balance in daily life. Participants are randomly assigned to an intervention and a control group. The intervention group follows a 12-week plantar intrinsic foot muscle strengthening training. The training consists of isolated and functional foot exercises to be performed 5 times a week, each session lasting approximately 20 min. The training is supervised once a week and the intensity gradually increases based on the participant's progression. Both groups keep a diary to report physical activities, fall incidents and movement related discomfort. The control condition is limited to keeping this diary. Data are collected at baseline and post-intervention. The trial outcomes are the between group differences in the mean change from baseline in maximum gait speed (primary outcome measure), capacity and strength of the plantar intrinsic foot muscles, foot and ankle biomechanics during gait, and various other fall risk-related variables. ANCOVA's are used to analyze the trial outcomes.

DISCUSSION

The results of this RCT will offer recommendations, related to plantar intrinsic foot muscle strengthening, to existing fall preventive exercise programs.

TRIAL REGISTRATION

The trial is registered in the United States National Library of Medicine through ClinicalTrials.gov (NCT05531136, 07/26/2022).

Hospital falls clinical practice guidelines: a global analysis and systematic review

BACKGROUND

Hospital falls continue to be a persistent global issue with serious harmful consequences for patients and health services. Many clinical practice guidelines now exist for hospital falls, and there is a need to appraise recommendations.

METHOD

A systematic review and critical appraisal of the global literature was conducted, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Web of Science, Embase, CINAHL, MEDLINE, Epistemonikos, Infobase of Clinical Practice Guidelines, Cochrane CENTRAL and PEDro databases were searched from 1 January 1993 to 1 February 2024. The quality of guidelines was assessed by two independent reviewers using Appraisal of Guidelines for Research and Evaluation Global Rating Scale and Appraisal of Guidelines of Research and Evaluation Recommendation Excellence (AGREE-REX). Certainty of findings was rated using Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research. Data were analysed using thematic synthesis.

RESULTS

2404 records were screened, 77 assessed for eligibility, and 20 hospital falls guidelines were included. Ten had high AGREE-REX quality scores. Key analytic themes were as follows: (i) there was mixed support for falls risk screening at hospital admission, but scored screening tools were no longer recommended; (ii) comprehensive falls assessment was recommended for older or frail patients; (iii) single and multifactorial falls interventions were consistently recommended; (iv) a large gap existed in patient engagement in guideline development and implementation; (v) barriers to implementation included ambiguities in how staff and patient falls education should be conducted, how delirium and dementia are managed to prevent falls, and documentation of hospital falls.

CONCLUSION

Evidence-based hospital falls guidelines are now available, yet systematic implementation across the hospital sector is more limited. There is a need to ensure an integrated and consistent approach to evidence-based falls prevention for a diverse range of hospital patients.

A Practice Guide for Physical Therapists Prescribing Physical Exercise for Older Adults

INTRODUCTION

Physical activity and exercise are protective factors for physical and cognitive decline in older adults, but recent studies reveal that a large percentage of this population do not practice exercise at the levels recommended by international guidelines. The frequency, intensity, type, time, volume, and progression (FITT-VP) principles are a widely used method for prescribing physical exercise, allowing the development of a personalized exercise program that meets the needs of each individual.

OBJECTIVES

This masterclass is intended to serve as a professional application tool for physical therapists who prescribe physical exercise for older adults. We present a section for each FITT-VP principle to facilitate handling these principles individually when prescribing exercise for this population.

METHODS

Review of the scientific literature and international guidelines on the prescription of physical exercises for older adults.

RESULTS

Aerobic, mobility, resistance, balance, and flexibility exercises, as well as functional training, should be included in an exercise program for older adults, which should be progressed using different methods for each of the exercise modalities.

CONCLUSIONS

An exercise program for older adults should integrate different exercise modalities. Exercise progression should be performed following the FITT-VP principles and some specific progression factors recommended for each exercise modality.

SIGNIFICANCE

Considering the challenge faced by clinicians in designing a viable exercise program for older adults that responds to international recommendations, with this masterclass we hope to help physical therapists to plan an exercise program that is feasible and at the same time, responds to the expected needs of this population.

Effects of Dalcroze Eurhythmics Exercise Versus Multicomponent Exercise on Physical and Cognitive Function, and Falls in Older Adults: The EPHYCOS Randomized Controlled Trial

Currently, robust evidence is lacking to support one exercise type over another in the prevention of physical and cognitive decline and falls among older adults, primarily because of the lack of comparative trials of proven interventions. Therefore, a 12-month randomized, single-blind, comparative effectiveness trial is conducted, in which 142 older adults at high risk for falls are randomized (1:1) to receive an evidence-based Dalcroze Eurhythmics (DE) exercise program (once weekly, group-based) or an evidence-based multicomponent (MULTI) exercise program incorporating balance, functional, and strength training activities (twice weekly, group- and home-based), for 12 months. The primary outcome is gait variability under dual-task at 12 months. At 12 months, the DE group has significant improvements compared with MULTI group on gait under both dual-task (adjusted β for stride variability: -2.3, 95%CI, -3.1 to -1.4; p < 0.001) and single-task, and on a variety of secondary physical and cognitive/executive function outcomes. The adjusted hazard ratio for falls is 0.58 (95%CI, 0.37 to 0.93) for the DE group compared with MULTI group. In conclusion, DE exercise is more effective than MULTI exercise in improving physical and cognitive function and reducing falls in older adults. The mechanisms underlying DE exercise-induced benefits remain to be fully elucidated.

Development of the Community-based complex Interventions to sustain Independence in Older People (CII-OP) typology: a qualitative synthesis of interventions in randomised controlled trials

INTRODUCTION

Community-based services to sustain independence for older people have varying configurations. A typology of these interventions would improve service provision and research by providing conceptual clarity and enabling the identification of effective configurations. We aimed to produce such a typology.

METHOD

We developed our typology by qualitatively synthesising community-based complex interventions to sustain independence in older people, evaluated in randomised controlled trials (RCTs), in four stages: (i) systematically identifying relevant RCTs; (ii) extracting descriptions of interventions (including control) using the Template for Intervention Description and Replication; (iii) generating categories of key intervention features and (iv) grouping the interventions based on these categories. PROSPERO registration: CRD42019162195.

RESULTS

Our search identified 129 RCTs involving 266 intervention arms. The Community-based complex Interventions to sustain Independence in Older People (CII-OP) typology comprises 14 action components and 5 tailoring components. Action components include procedures for treating patients or otherwise intended to directly improve their outcomes; regular examples include formal homecare; physical exercise; health education; activities of daily living training; providing aids and adaptations and nutritional support. Tailoring components involve a process that may result in care planning, with multiple action components being planned, recommended or prescribed. Multifactorial action from care planning was the most common tailoring component. It involves individualised, multidomain assessment and management, as in comprehensive geriatric assessment. Sixty-three different intervention types (combinations) were identified.

CONCLUSIONS

Our typology provides an empirical basis for service planning and evidence synthesis. We recommend better reporting about organisational aspects of interventions and usual care.

Applying behaviour change theory to parent-led language interventions for children in the early years

BACKGROUND

The aim of many interventions used by speech and language therapists (SLTs) is to change behaviours related to communication and interaction. Parent-led language interventions for children in the early years (0-5 years) rely on SLTs supporting parents to change their behaviour in child-focused interactions to effect a change in the child's communication. Therapeutic techniques used by SLTs in parent-led language interventions are largely underspecified, impacting on intervention reporting, replication, trialling and development. The Behaviour Change Technique Taxonomy Version 1 (BCTTv1) offers a method of describing intervention techniques developed for use in public health interventions, but with several examples of its application to speech and language interventions.

AIMS

To identify behaviour change techniques (BCTs) from the BCTTv1 occurring in parent-led language interventions for children in the early years.

METHODS & PROCEDURES

A literature search identified relevant descriptions of parent-led language interventions. These were coded using the BCTTv1. A reliability check was carried out on 10% of the descriptions. To confirm the use of identified BCTs in clinical practice, results of the literature search were triangulated with an online survey of SLTs, and observations of SLTs delivering parent-led language intervention.

OUTCOMES & RESULTS

A total of 84 papers containing descriptions of 45 interventions were coded; 62 SLTs responded to the survey and three SLTs were observed delivering parent-led language intervention. A total of 24 BCTs were identified in the literature search, replicated in the observations and verified by SLTs in the survey. BCTs were identified at two levels: Level 1 SLT implemented to change parent interactive behaviour; and Level 2 parent implemented to change child communicative behaviour.

CONCLUSIONS & IMPLICATIONS

The BCTTv1 is a useful starting place for describing parent-led language interventions. With some additions and adjustments, BCTs identified in this study were immediately recognized by practitioners and can easily be adopted into practice.

WHAT THIS PAPER ADDS

What is already known on this subject Techniques used in SLT interventions are often not clearly described. The BCTTv1 has been used to clarify technique descriptions with success in a small number of SLT disciplines, but not yet in parent-led language interventions for preschoola children. What this paper adds to the existing knowledge This paper constitutes the first research into quantifying the techniques used in parent-led language interventions using the BCTTv1. What are the potential or actual clinical implications of this work? This paper provides a clear list of techniques used by SLTs implementing interventions for preschool children, which can be immediately adopted and used in practice. It also highlights potential adjustments and gaps in the BCTTv1 in relation to SLT which can contribute to future iterations.

Effectiveness of dance interventions for falls prevention in older adults: systematic review and meta-analysis

INTRODUCTION

Fall prevention is a global health priority. Strength and balance exercise programmes are effective at reducing falls. Emerging literature suggests dance is an enjoyable and sociable form of exercise. However, there is little evidence that dance reduces fall incidence.

METHODS

Systematic review and meta-analysis examining effectiveness and cost-effectiveness of dance for falls prevention in older adults. Five databases were searched with no restrictions on publication date or intervention settings. Risk of bias was assessed using variants of Cochrane Risk of bias tools, Mixed-Methods Appraisal and Drummond checklist as appropriate. Certainty of evidence was assessed using GRADE.

RESULTS

Forty-one studies were included (19 RCTs, 13 quasi-experimental, two mixed-method, seven observational studies, 2,451 participants). Five types of dance interventions were identified: ballroom and Latin dance, dance exercise, cultural dance, dance therapy, and low-impact dance. Meta-analysis was only possible for functional outcome measures: Timed-Up-and-Go (dance versus usual care, mean difference (MD) = 1.36; 95% CI -3.57 to 0.85), Sit-to-Stand (dance versus exercise MD = -0.85; 95% CI -2.64 to 0.93: dance versus education MD = -1.64; 95% CI -4.12 to 0.85), Berg Balance Scale (dance versus usual care MD = 0.61; 95% CI -4.26 to 5.47). There was unexplained variance in effects and no significant differences between intervention and control groups. Overall, certainty of evidence was very low; we are uncertain about the effect of dance interventions in reducing falls.

CONCLUSIONS

There is very low certainty evidence for dance as an alternative to strength and balance training if the aim is to prevent falls. No robust evidence on the cost-effectiveness of dance interventions for the prevention of falls was found.

PROSPERO REGISTRATION

CRD42022382908.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements. We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 154 RCTs with a total of 7837 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 60 (2721 participants), and 48 (3029 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson's Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (60 studies; 2721 participants) suggests that dance and gait/balance/functional training probably have a moderate beneficial effect on the severity of motor signs (dance: mean difference (MD) -10.18, 95% confidence interval (CI) -14.87 to -5.36; gait/balance/functional training: MD -7.50, 95% CI -11.39 to -3.48; moderate confidence), and multi-domain training probably has a small beneficial effect on the severity of motor signs (MD -5.90, 95% CI -9.11 to -2.68; moderate confidence). The evidence also suggests that endurance, aqua-based, strength/resistance, and mind-body training might have a small beneficial effect on the severity of motor signs (endurance training: MD -5.76, 95% CI -9.78 to -1.74; aqua-based training: MD -5.09, 95% CI -10.45 to 0.40; strength/resistance training: MD -4.96, 95% CI -9.51 to -0.40; mind-body training: MD -3.62, 95% CI -7.24 to 0.00; low confidence). The evidence is very uncertain about the effects of "Lee Silverman Voice training BIG" (LSVT BIG) and flexibility training on the severity of motor signs (LSVT BIG: MD -6.70, 95% CI -16.48 to 3.08; flexibility training: MD 4.20, 95% CI -1.61 to 9.92; very low confidence). Quality of life The evidence from the NMA (48 studies; 3029 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -15.15, 95% CI -23.43 to -6.87; moderate confidence). The evidence also suggests that mind-body, gait/balance/functional, and multi-domain training and dance might have a small beneficial effect on QoL (mind-body training: MD -7.22, 95% CI -13.57 to -0.70; gait/balance/functional training: MD -6.17, 95% CI -10.75 to -1.59; multi-domain training: MD -5.29, 95% CI -9.51 to -1.06; dance: MD -3.88, 95% CI -10.92 to 3.00; low confidence). The evidence is very uncertain about the effects of gaming, strength/resistance, endurance, and flexibility training on QoL (gaming: MD -8.99, 95% CI -23.43 to 5.46; strength/resistance training: MD -6.70, 95% CI -12.86 to -0.35; endurance training: MD -6.52, 95% CI -13.74 to 0.88; flexibility training: MD 1.94, 95% CI -10.40 to 14.27; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

A Stepped-Wedge Cluster-Randomized Controlled Trial of a Multi-interventional Approach for Fall Prevention

BACKGROUND AND OBJECTIVES

Falls are one of the most common adverse events at hospitals that may result in injury and even death. They are also associated with raised length of stay (LOS) and hospitalization costs. This experiment aimed to examine the effectiveness of multiple interventions in reducing inpatient fall rates and the consequent injuries.

METHODS

The present study was a stepped-wedge cluster-randomized controlled trial. It was done in 18 units in a public university hospital over 36 weeks. Patients included in this research were at risk of falls. Overall, 33 856 patients were admitted, of whom 4766 were considered high-risk patients. During the intervention phases, a series of preventive and control measures were considered, namely staff training; patient education; placement of nursing call bells; adequate lighting; supervision of high-risk patients during transmission and handovers; mobility device allocation; placement of call bell and safe guard in bathrooms; placing "fall alert" signs above patients' beds; nurses informing physicians timely about complications such as delirium and hypoxia; encouraging appropriate use of eyeglasses, hearing aids and footwear; keeping side rails up; and reassessing patients after each fall. The primary outcome was participant falls per 1000 patient-days. Secondary outcomes were fall-related injuries and LOS.

RESULTS

The results revealed a decrease in fall rate (n = 4 per 1000 patient-days vs 1.34 per 1000 patient-days, incidence rate ratio (IRR) = 0.19 [95% confidence interval (CI), 0.14-0.26]; P = .001) and injuries (n = 2.4 per 1000 patient-days vs 0.79 per 1000 patient-days, IRR = 0.22 [95% CI, 0.15-0.32]; P = .001) in exposed compared with unexposed phases. There was not a significant difference in LOS (exposed mean 10.63 days [95% CI, 10.26-10.97], unexposed mean 10.84 days [95% CI, 10.59-11.09], mean difference = -0.13 [95% CI, -0.53 to 0.27], P = .52).

CONCLUSIONS

This multi-interventional trial showed a reduction in falls and fall rates with injury but without an overall effect on LOS. Further research is needed to understand the sustainability of multiple fall prevention strategies in hospitals and their long-term impacts.

Population-based interventions for preventing falls and fall-related injuries in older people

BACKGROUND

Around one-third of older adults aged 65 years or older who live in the community fall each year. Interventions to prevent falls can be designed to target the whole community, rather than selected individuals. These population-level interventions may be facilitated by different healthcare, social care, and community-level agencies. They aim to tackle the determinants that lead to risk of falling in older people, and include components such as community-wide polices for vitamin D supplementation for older adults, reducing fall hazards in the community or people's homes, or providing public health information or implementation of public health programmes that reduce fall risk (e.g. low-cost or free gym membership for older adults to encourage increased physical activity).

OBJECTIVES

To review and synthesise the current evidence on the effects of population-based interventions for preventing falls and fall-related injuries in older people. We defined population-based interventions as community-wide initiatives to change the underlying societal, cultural, or environmental conditions increasing the risk of falling.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in December 2020, and conducted a top-up search of CENTRAL, MEDLINE, and Embase in January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, trials with stepped-wedge designs, and controlled non-randomised studies evaluating population-level interventions for preventing falls and fall-related injuries in adults ≥ 60 years of age. Population-based interventions target entire communities. We excluded studies only targeting people at high risk of falling or with specific comorbidities, or residents living in institutionalised settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and used GRADE to assess the certainty of the evidence. We prioritised seven outcomes: rate of falls, number of fallers, number of people experiencing one or more fall-related injuries, number of people experiencing one or more fall-related fracture, number of people requiring hospital admission for one or more falls, adverse events, and economic analysis of interventions. Other outcomes of interest were: number of people experiencing one or more falls requiring medical attention, health-related quality of life, fall-related mortality, and concerns about falling.

MAIN RESULTS

We included nine studies: two cluster RCTs and seven non-randomised trials (of which five were controlled before-and-after studies (CBAs), and two were controlled interrupted time series (CITS)). The numbers of older adults in intervention and control regions ranged from 1200 to 137,000 older residents in seven studies. The other two studies reported only total population size rather than numbers of older adults (67,300 and 172,500 residents). Most studies used hospital record systems to collect outcome data, but three only used questionnaire data in a random sample of residents; one study used both methods of data collection. The studies lasted between 14 months and eight years. We used Prevention of Falls Network Europe (ProFaNE) taxonomy to classify the types of interventions. All studies evaluated multicomponent falls prevention interventions. One study (n = 4542) also included a medication and nutrition intervention. We did not pool data owing to lack of consistency in study designs. Medication or nutrition Older people in the intervention area were offered free-of-charge daily supplements of calcium carbonate and vitamin D3. Although female residents exposed to this falls prevention programme had fewer fall-related hospital admissions (with no evidence of a difference for male residents) compared to a control area, we were unsure of this finding because the certainty of evidence was very low. This cluster RCT included high and unclear risks of bias in several domains, and we could not determine levels of imprecision in the effect estimate reported by study authors. Because this evidence is of very low certainty, we have not included quantitative results here. This study reported none of our other review outcomes. Multicomponent interventions Types of interventions included components of exercise, environment modification (home; community; public spaces), staff training, and knowledge and education. Studies included some or all of these components in their programme design. The effectiveness of multicomponent falls prevention interventions for all reported outcomes is uncertain. The two cluster RCTs included high or unclear risk of bias, and we had no reasons to upgrade the certainty of evidence from the non-randomised trial designs (which started as low-certainty evidence). We also noted possible imprecision in some effect estimates and inconsistent findings between studies. Given the very low-certainty evidence for all outcomes, we have not reported quantitative findings here. One cluster RCT reported lower rates of falls in the intervention area than the control area, with fewer people in the intervention area having one or more falls and fall-related injuries, but with little or no difference in the number of people having one or more fall-related fractures. In another cluster RCT (a multi-arm study), study authors reported no evidence of a difference in the number of female or male residents with falls leading to hospital admission after either a multicomponent intervention ("environmental and health programme") or a combination of this programme and the calcium and vitamin D3 programme (above). One CBA reported no difference in rate of falls between intervention and control group areas, and another CBA reported no difference in rate of falls inside or outside the home. Two CBAs found no evidence of a difference in the number of fallers, and another CBA found no evidence of a difference in fall-related injuries. One CITS found no evidence of a difference in the number of people having one or more fall-related fractures. No studies reported adverse events.

AUTHORS' CONCLUSIONS

Given the very low-certainty evidence, we are unsure whether population-based multicomponent or nutrition and medication interventions are effective at reducing falls and fall-related injuries in older adults. Methodologically robust cluster RCTs with sufficiently large communities and numbers of clusters are needed. Establishing a rate of sampling for population-based studies would help in determining the size of communities to include. Interventions should be described in detail to allow investigation of effectiveness of individual components of multicomponent interventions; using the ProFaNE taxonomy for this would improve consistency between studies.

Digital technologies to prevent falls in people living with dementia or mild cognitive impairment: a rapid systematic overview of systematic reviews

OBJECTIVE

Falls are a common cause of potentially preventable death, disability and loss of independence with an annual estimated cost of £4.4bn. People living with dementia (PlwD) or mild cognitive impairment (MCI) have an increased fall risk. This overview evaluates evidence for technologies aiming to reduce falls and fall risk for PlwD or MCI.

METHODS

In October 2022, we searched five databases for evidence syntheses. We used standard methods to rapidly screen, extract data, assess risk of bias and overlap, and synthesise the evidence for each technology type.

RESULTS

We included seven systematic reviews, incorporating 22 relevant primary studies with 1,412 unique participants. All reviews had critical flaws on AMSTAR-2: constituent primary studies were small, heterogeneous, mostly non-randomised and assessed as low or moderate quality. Technologies assessed were: wearable sensors, environmental sensor-based systems, exergaming, virtual reality systems. We found no evidence relating to apps. Review evidence for the direct impact on falls was available only from environmental sensors, and this was inconclusive. For wearables and virtual reality technologies there was evidence that technologies may differentiate PlwD who fell from those who did not; and for exergaming that balance may be improved.

CONCLUSIONS

The evidence for technology to reduce falls and falls risk for PlwD and MCI is methodologically weak, based on small numbers of participants and often indirect. There is a need for higher-quality RCTs to provide robust evidence for effectiveness of fall prevention technologies. Such technologies should be designed with input from users and consideration of the wider implementation context.

Exercise for falls prevention in aged care: systematic review and trial endpoint meta-analyses

BACKGROUND

There is strong evidence that exercise reduces falls in older people living in the community, but its effectiveness in residential aged care is less clear. This systematic review examines the effectiveness of exercise for falls prevention in residential aged care, meta-analysing outcomes measured immediately after exercise or after post-intervention follow-up.

METHODS

Systematic review and meta-analysis, including randomised controlled trials from a Cochrane review and additional trials, published to December 2022. Trials of exercise as a single intervention compared to usual care, reporting data suitable for meta-analysis of rate or risk of falls, were included. Meta-analyses were conducted according to Cochrane Collaboration methods and quality of evidence rated using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

12 trials from the Cochrane review plus 7 new trials were included. At the end of the intervention period, exercise probably reduces the number of falls (13 trials, rate ratio [RaR] = 0.68, 95% confidence interval [CI] = 0.49-0.95), but after post-intervention follow-up exercise had little or no effect (8 trials, RaR = 1.01, 95% CI = 0.80-1.28). The effect on the risk of falling was similar (end of intervention risk ratio (RR) = 0.84, 95% CI = 0.72-0.98, 12 trials; post-intervention follow-up RR = 1.05, 95% CI = 0.92-1.20, 8 trials). There were no significant subgroup differences according to cognitive impairment.

CONCLUSIONS

Exercise is recommended as a fall prevention strategy for older people living in aged care who are willing and able to participate (moderate certainty evidence), but exercise has little or no lasting effect on falls after the end of a programme (high certainty evidence).

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

BACKGROUND

Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour.

OBJECTIVES

To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies.

SELECTION CRITERIA

This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition.

DATA COLLECTION AND ANALYSIS

Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions.

AUTHORS' CONCLUSIONS

CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

Critical features of multifactorial interventions for effective falls reduction in residential aged care: a systematic review, intervention component analysis and qualitative comparative analysis

BACKGROUND

Multifactorial fall prevention trials providing interventions based on individual risk factors have variable success in aged care facilities. To determine configurations of trial features that reduce falls, intervention component analysis (ICA) and qualitative comparative analysis (QCA) were undertaken.

METHODS

Randomised controlled trials (RCTs) from a Cochrane Collaboration review (Cameron, 2018) with meta-analysis data, plus trials identified in a systematic search update to December 2021 were included. Meta-analyses were updated. A theory developed through ICA of English publications of trialist's perspectives was assessed through QCA and a subgroup meta-analysis.

RESULTS

Pooled effectiveness of multifactorial interventions indicated a falls rate ratio of 0.85 (95% confidence interval, CI, 0.65-1.10; I2 = 85%; 11 trials). All tested interventions targeted both environmental and personal risk factors by including assessment of environmental hazards, a medical or medication review and exercise intervention. ICA emphasised the importance of co-design involving facility staff and managers and tailored intervention delivery to resident's intrinsic factors for successful outcomes. QCA of facility engagement plus tailored delivery was consistent with greater reduction in falls, supported by high consistency (0.91) and coverage (0.85). An associated subgroup meta-analysis demonstrated strong falls reduction without heterogeneity (rate ratio 0.61, 95%CI 0.54-0.69, I2 = 0%; 7 trials).

CONCLUSION

Multifactorial falls prevention interventions should engage aged care staff and managers to implement strategies which include tailored intervention delivery according to each resident's intrinsic factors. Such approaches are consistently associated with a successful reduction in falls, as demonstrated by QCA and subgroup meta-analyses. Co-design approaches may also enhance intervention success.

Interventions to reduce falls in community-dwelling adults with intellectual disability: a systematic review

BACKGROUND

People with intellectual disability have a high risk of falls and falls-related injuries. Although people with intellectual disability are at increased risk of falls, there is a need to better understand the efficacy of interventions that can help reduce falls and address risk factors in this population. This systematic review aimed to evaluate the type, nature and effectiveness of interventions undertaken to reduce falls with community-dwelling adults with intellectual disability and the quality of this evidence.

METHOD

Four electronic databases were searched: Ovid MEDLINE, PsycINFO, CINAHL Plus and the Cochrane Library. Studies were included if they involved people aged 18 years or over, at least 50% of study participants had intellectual disability, participants were community-dwelling, and the study evaluated any interventions aiming to reduce falls. Study quality was assessed using the National Institutes of Health study quality assessment tools. Reporting of the review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Seven studies were eligible for review, with a total of 286 participants and mean age of 50.4 years. As only one randomised trial was identified, a narrative synthesis of results was undertaken. Five studies evaluated exercise interventions, one evaluated a falls clinic programme, and one evaluated stretch fabric splinting garments. Methodological quality varied (two studies rated as good, four as fair, and one as poor). Exercise interventions varied in terms of exercise type and dosage, frequency and intensity, and most did not align with recommendations for successful falls prevention exercise interventions reported for older people. While the majority of studies reported reduced falls, they differed in methods of reporting falls, and most did not utilise statistical analyses to evaluate outcomes.

CONCLUSION

This review identified a small number of falls prevention intervention studies for people with intellectual disability. Although several studies reported improvements in fall outcomes, ability to draw conclusions about intervention effectiveness is limited by small sample sizes and few studies. Further large-scale research is required to implement and evaluate falls prevention interventions specifically for adults with intellectual disability.

Effectiveness of Exercise Interventions for Preventing Neck Pain: A Systematic Review With Meta-analysis of Randomized Controlled Trials

OBJECTIVE: To update the evidence on the effectiveness of exercise interventions to prevent episodes of neck pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, SPORTDiscus, PEDro, and trial registries from inception to December 2, 2022. Forward and backward citation searches. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled adults without neck pain at baseline and compared exercise interventions to no intervention, placebo/sham, attention control, or minimal intervention. Military populations and astronauts were excluded. DATA SYNTHESIS: Random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 tool. The certainty of evidence was judged according to the GRADE approach. RESULTS: Of 4703 records screened, 5 trials (1722 participants at baseline) were included and eligible for meta-analysis. Most (80%) participants were office workers. Risk of bias was rated as some concerns for 2 trials and high for 3 trials. There was moderate-certainty evidence that exercise interventions probably reduce the risk of a new episode of neck pain (OR, 0.49; 95% confidence interval: 0.31, 0.76) compared to no or minimal intervention in the short-term (≤12 months). The results were not robust to sensitivity analyses for missing outcome data. CONCLUSION: There was moderate-certainty evidence supporting exercise interventions for reducing the risk for an episode of neck pain in the next 12 months. The clinical significance of the effect is unclear. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub: 8 September 2023. doi:10.2519/jospt.2023.12063.

Effects of Physical Activity Interventions on Strength, Balance and Falls in Middle-Aged Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Weak lower body strength and balance impairments are fundamental risk factors for mobility impairments and falls that can be improved by physical activity (PA). Previous meta-analyses have focused on these risk factors in adults aged ≥ 65 years. Yet, the potential of PA for improving these risk factors in middle-aged populations has not been systematically investigated. This systematic review and meta-analysis aim to examine the effect of general and structured PA on lower limb strength, postural balance and falls in middle-aged adults.

METHODS

A computerized systematic literature search was conducted in the electronic databases MEDLINE, CINAHL, Web of Science and Cochrane Library. PA intervention types were classified according to the ProFaNE taxonomy. Randomized controlled trials exploring the effects of PA on strength (e.g., leg press one-repetition-maximum), balance (e.g., single limb stance) and falls (e.g., fall rates) in adults aged 40-60 years were systematically searched and included in a network analysis. Moderator analyses were performed for specific subgroups (age, sex, low PA). The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database (PEDro) Scale.

RESULTS

Out of 7170 articles screened, 66 studies (median PEDro score 5) with 3387 participants were included. Strong, significant effects on muscle strength were found for strength (SMD = 1.02), strength-aerobic (SMD = 1.41), strength-endurance (SMD = 0.92) and water-based (SMD = 1.08) training (52 studies, I² = 79.3%). Strength training (SMD = 1.16), strength-aerobic (SMD = 0.98) and 3D training (SMD = 1.31) improved postural balance (30 studies, I² = 88.1%). Moderator analyses revealed significant effects of specific intervention types on certain subgroups and subdomains of strength and balance. No studies were found measuring falls.

CONCLUSIONS

Structured PA interventions in middle-aged adults improve strength and balance outcomes related to functional impairments and falls. Strength training increases both strength and balance and can be recommended to prevent age-related functional decline. However, the interpretability of the results is limited due to considerable heterogeneity and the overall low methodological quality of the included studies. Long-term trials are needed to determine the preventive potential of PA on strength, balance and falls. This meta-analysis may inform guidelines for tailored training during middle age to promote healthy aging. Prospero registration: CRD42020218643.

Case management for integrated care of older people with frailty in community settings

BACKGROUND

Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems.

OBJECTIVES

To assess the effects of case management for integrated care of older people living with frailty compared with usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care.

AUTHORS' CONCLUSIONS

We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

Influencing factors of interprofessional collaboration in multifactorial fall prevention interventions: a qualitative systematic review

BACKGROUND

With the ageing population worldwide, falls are becoming a severe and growing health problem. Interprofessional multifactorial fall prevention interventions (FPIs) have effectively prevented falls in community-dwelling older adults. However, the implementation of FPIs often fails due to a lack of interprofessional collaboration. Therefore, gaining insight into the influencing factors of interprofessional collaboration in multifactorial FPI's for older adults living in the community is essential. Consequently, our aim was to provide an overview of factors influencing interprofessional collaboration in multifactorial FPIs for community-dwelling older adults.

METHODS

This qualitative systematic literature research was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Pubmed, CINAHL, and Embase electronic databases have been systematically searched for eligible articles, with a qualitative design. The quality was appraised using the Checklist for Qualitative Research by the Joann Briggs Institute. The findings were inductively synthesized using a meta-aggregative approach. Confidence in the synthesized findings was established using the ConQual methodology.

RESULTS

Five articles were included. Analysis of the included studies resulted in 31 influencing factors for interprofessional collaboration, which were labelled as findings. These findings were summarized in ten categories and combined into five synthesized findings. Results showed that communication, role clarity, information sharing, organization, and interprofessional aim influence interprofessional collaboration in multifactorial FPIs.

CONCLUSIONS

This review provides a comprehensive summary of findings on interprofessional collaboration, specifically in the context of multifactorial FPIs. Knowledge in this area is considerably relevant given the multifactorial nature of falls, which demands an integrated, multidomain approach, including both health and social care. The results can be utilized as a fundament for developing effective implementation strategies aiming to improve interprofessional collaboration between health and social care professionals working in multifactorial FPIs in the community.

Strength-training and balance activities in Canada: historical trends and current prevalence

INTRODUCTION

Muscle-strengthening and balance activities are associated with the prevention of illness and injury. Age-specific Canadian 24-Hour Movement Guidelines include recommendations for muscle/bone-strengthening and balance activities. From 2000-2014, the Canadian Community Health Survey (CCHS) included a module that assessed frequency in 22 physical activities. In 2020, a healthy living rapid response module (HLV-RR) on the CCHS asked new questions on the frequency of muscle/bonestrengthening and balance activities. The objectives of the study were to (1) estimate and characterize adherence to meeting the muscle/bone-strengthening and balance recommendations; (2) examine associations between muscle/bone-strengthening and balance activities with physical and mental health; and (3) examine trends (2000-2014) in adherence to recommendations.

METHODS

Using data from the 2020 CCHS HLV-RR, we estimated age-specific prevalence of meeting recommendations. Multivariate logistic regressions examined associations with physical and mental health. Using data from the 2000-2014 CCHS, sex-specific temporal trends in recommendation adherence were explored using logistic regression.

RESULTS

Youth aged 12 to 17 years (56.6%, 95% CI: 52.4-60.8) and adults aged 18 to 64 years (54.9%, 95% CI: 53.1-56.8) had significantly greater adherence to the muscle/ bone-strengthening recommendation than adults aged 65 years and older (41.7%, 95% CI: 38.9-44.5). Only 16% of older adults met the balance recommendation. Meeting the recommendations was associated with better physical and mental health. The proportion of Canadians who met the recommendations increased between 2000 and 2014.

CONCLUSION

Approximately half of Canadians met their age-specific muscle/bonestrengthening recommendations. Reporting on the muscle/bone-strengthening and balance recommendations elevates their importance alongside the already recognized aerobic recommendation.

Home Modifications for Older Adults: A Systematic Review

While ≧10,000 Americans turn 65 years old every day, only 10% of American homes are "aging ready." Unsafe homes can exacerbate disability, lead to falls, and increase the likelihood of hospitalization. With increased investments in home and community-based services, public health stakeholders are considering home modifications to promote successful aging. While several home modification models exist, there is significant heterogeneity between models and no consensus on critical features. PubMed, EMBASE, and Web of Science were reviewed and twelve randomized controlled trials of home modifications for older adults were identified and evaluated for model structure, reported outcomes, and risk of bias. Overall, occupational therapist-driven home modifications supplemented with clinical, physical activity, and/or behavioral components saw the greatest success. This systematic review discusses the components of these models, highlights particularly effective and frequently used features, and the practice and research needed to create effective next-generation home modification models which promote healthy longevity.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements.  We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 156 RCTs with a total of 7939 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 71 (3196 participants), and 55 (3283 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (71 studies; 3196 participants) suggests that dance has a moderate beneficial effect on the severity of motor signs (mean difference (MD) -10.32, 95% confidence interval (CI) -15.54 to -4.96; high confidence), and aqua-based, gait/balance/functional, and multi-domain training might have a moderate beneficial effect on the severity of motor signs (aqua-based: MD -7.77, 95% CI -13.27 to -2.28; gait/balance/functional: MD -7.37, 95% CI -11.39 to -3.35; multi-domain: MD -6.97, 95% CI -10.32 to -3.62; low confidence). The evidence also suggests that mind-body training and endurance training might have a small beneficial effect on the severity of motor signs (mind-body: MD -6.57, 95% CI -10.18 to -2.81; endurance: MD -6.43, 95% CI -10.72 to -2.28; low confidence). Flexibility training might have a trivial or no effect on the severity of motor signs (MD 2.01, 95% CI -4.82 to 8.98; low confidence). The evidence is very uncertain about the effects of strength/resistance training and "Lee Silverman Voice training BIG" (LSVT BIG) on the severity of motor signs (strength/resistance: MD -6.97, 95% CI -11.93 to -2.01; LSVT BIG: MD -5.49, 95% CI -14.74 to 3.62; very low confidence). Quality of life The evidence from the NMA (55 studies; 3283 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -14.98, 95% CI -23.26 to -6.52; moderate confidence). The evidence also suggests that endurance training might have a moderate beneficial effect, and that gait/balance/functional and multi-domain training might have a small beneficial effect on QoL (endurance: MD -9.16, 95% CI -15.68 to -2.82; gait/balance/functional: MD -5.64, 95% CI -10.04 to -1.23; multi-domain: MD -5.29, 95% CI -9.34 to -1.06; low confidence). The evidence is very uncertain about the effects of mind-body training, gaming, strength/resistance training, dance, LSVT BIG, and flexibility training on QoL (mind-body: MD -8.81, 95% CI -14.62 to -3.00; gaming: MD -7.05, 95% CI -18.50 to 4.41; strength/resistance: MD -6.34, 95% CI -12.33 to -0.35; dance: MD -4.05, 95% CI -11.28 to 3.00; LSVT BIG: MD 2.29, 95% CI -16.03 to 20.44; flexibility: MD 1.23, 95% CI -11.45 to 13.92; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

Economic evaluations of fall prevention exercise programs: a systematic review

Objective

To investigate cost-effectiveness and costs of fall prevention exercise programmes for older adults.

Design

Systematic review.

Data sources

Medline, Embase, Web of Science, Scopus, National Institute for Health Research Economic Evaluation Database, Health Technology Assessment database, Tufts Cost-Effectiveness Analysis Registry, Research Papers in Economics and EconLit (inception to May 2022).

Eligibility criteria for study selection

Economic evaluations (trial-based or model-based) and costing studies investigating fall prevention exercise programmes versus no intervention or usual care for older adults living in the community or care facilities, and reporting incremental cost-effectiveness ratio (ICER) for fall-related outcomes or quality-adjusted life years (QALY, expressed as cost/QALY) and/or intervention costs.

Results

31 studies were included. For community-dwelling older adults (21 economic evaluations, 6 costing studies), results ranged from more effective and less costly (dominant) interventions up to an ICER of US$279 802/QALY gained and US$11 986/fall prevented (US$ in 2020). Assuming an arbitrary willingness-to-pay threshold (US$100 000/QALY), most results (17/24) were considered cost-effective (moderate certainty). The greatest value for money (lower ICER/QALY gained and fall prevented) appeared to accrue for older adults and those with high fall risk, but unsupervised exercise appeared to offer poor value for money (higher ICER/QALY). For care facilities (two economic evaluations, two costing studies), ICERs ranged from dominant (low certainty) to US$35/fall prevented (moderate certainty). Overall, intervention costs varied and were poorly reported.

Conclusions

Most economic evaluations investigated fall prevention exercise programmes for older adults living in the community. There is moderate certainty evidence that fall prevention exercise programmes are likely to be cost-effective. The evidence for older adults living in care facilities is more limited but promising.

PROSPERO registration number

PROSPERO 2020 CRD42020178023.

Disentangling interventions to reduce fear of falling in community-dwelling older people: a systematic review and meta-analysis of intervention components

PURPOSE

Fear of falling (FoF) is a common and debilitating problem for older people. Most multicomponent interventions show only moderate effects. Exploring the effective components may help in the optimization of treatments for FoF.

MATERIALS AND METHODS

In a systematic review of five scientific literature databases, we identified randomized controlled trials with older community-dwelling people that included FoF as an outcome. There was no restriction on types of interventions. Two reviewers extracted information about outcomes and content of interventions. Intervention content was coded with a coding scheme of 68 intervention components. We compared all studies with a component to those without using univariate meta-regressions.

RESULTS

Sixty-six studies, reporting on 85 interventions, were included in the systematic review. In the meta-regressions (n = 49), few components were associated with intervention effects at the first available follow up after the intervention, but interventions with meditation, holistic exercises (such as Tai Chi or Pilates) or body awareness were significantly more effective than interventions without these components. Interventions with self-monitoring, balance exercises, or tailoring were less effective compared to those without these components.

CONCLUSIONS

The identified components may be important for the design and optimization of treatments to reduce FoF. Implications for rehabilitationFear of falling (FoF) is a common and debilitating issue among older people and multicomponent interventions usually show only small to moderate effects on FoF.This review and meta-analysis investigated 68 intervention components and their relation to intervention effects on FoF.Interventions with meditation, holistic exercises (such as Tai Chi), or body awareness are more effective than interventions without these components.Clinicians aiming to reduce FoF may recommend selected interventions to older people taking into account the current knowledge of intervention components.

Interventions for improving mobility after hip fracture surgery in adults

BACKGROUND

Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.

OBJECTIVES

To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).

DATA COLLECTION AND ANALYSIS

Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.

MAIN RESULTS

We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.

AUTHORS' CONCLUSIONS

Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.

Mobility training for increasing mobility and functioning in older people with frailty

BACKGROUND

Frailty is common in older people and is characterised by decline across multiple body systems, causing decreased physiological reserve and increased vulnerability to adverse health outcomes. It is estimated that 21% of the community-dwelling population over 65 years are frail. Frailty is independently predictive of falls, worsening mobility, deteriorating functioning, impaired activities of daily living, and death. The World Health Organization's International Classification of Functioning, Disability and Health (ICF) defines mobility as: changing and maintaining a body position, walking, and moving. Common interventions used to increase mobility include functional exercises, such as sit-to-stand, walking, or stepping practice.

OBJECTIVES

To summarise the evidence for the benefits and safety of mobility training on overall functioning and mobility in frail older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, AMED, PEDro, US National Institutes of Health Ongoing Trials Register, and the World Health Organization International Clinical Trials Registry Platform (June 2021).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effects of mobility training on mobility and function in frail people aged 65+ years living in the community. We defined community as those residing either at home or in places that do not provide rehabilitative services or residential health-related care, for example, retirement villages, sheltered housing, or hostels.  DATA COLLECTION AND ANALYSIS: We undertook an 'umbrella' comparison of all types of mobility training versus control.

MAIN RESULTS

This review included 12 RCTs, with 1317 participants, carried out in 9 countries. The median number of participants in the trials was 97. The mean age of the included participants was 82 years. The majority of trials had unclear or high risk of bias for one or more items. All trials compared mobility training with a control intervention (defined as one that is not thought to improve mobility, such as general health education, social visits, very gentle exercise, or "sham" exercise not expected to impact on mobility). High-certainty evidence showed that mobility training improves the level of mobility upon completion of the intervention period. The mean mobility score was 4.69 in the control group, and with mobility training, this score improved by 1.00 point (95% confidence interval (CI) 0.51 to 1.51) on the Short Physical Performance Battery (on a scale of 0 to 12; higher scores indicate better mobility levels) (12 studies, 1151 participants). This is a clinically significant change (minimum clinically important difference: 0.5 points; absolute improvement of 8% (4% higher to 13% higher); number needed to treat for an additional beneficial outcome (NNTB) 5 (95% CI 3.00 to 9.00)). This benefit was maintained at six months post-intervention. Moderate-certainty evidence (downgraded for inconsistency) showed that mobility training likely improves the level of functioning upon completion of the intervention. The mean function score was 86.1 in the control group, and with mobility training, this score improved by 8.58 points (95% CI 3.00 to 14.30) on the Barthel Index (on a scale of 0 to 100; higher scores indicate better functioning levels) (9 studies, 916 participants) (absolute improvement of 9% (3% higher to 14% higher)). This result did not reach clinical significance (9.8 points). This benefit did not appear to be maintained six months after the intervention. We are uncertain of the effect of mobility training on adverse events as we assessed the certainty of the evidence as very low (downgraded one level for imprecision and two levels for bias). The number of events was 771 per 1000 in the control group and 562 per 1000 in the group with mobility training (risk ratio (RR) 0.74, 95% CI 0.63 to 0.88; 2 studies, 225 participants) (absolute difference of 19% fewer (9% fewer to 26% fewer)). Mobility training may result in little to no difference in the number of people who are admitted to nursing care facilities at the end of the intervention period as the 95% confidence interval includes the possibility of both a reduced and increased number of admissions to nursing care facilities (low-certainty evidence, downgraded for imprecision and bias). The number of events was 248 per 1000 in the control group and 208 per 1000 in the group with mobility training (RR 0.84, 95% CI 0.53 to 1.34; 1 study, 241 participants) (absolute difference of 4% fewer (8% more to 12% fewer)). Mobility training may result in little to no difference in the number of people who fall as the 95% confidence interval includes the possibility of both a reduced and increased number of fallers (low-certainty evidence, downgraded for imprecision and study design limitations). The number of events was 573 per 1000 in the control group and 584 per 1000 in the group with mobility training (RR 1.02, 95% CI 0.87 to 1.20; 2 studies, 425 participants) (absolute improvement of 1% (12% more to 7% fewer)). Mobility training probably results in little to no difference in the death rate at the end of the intervention period as the 95% confidence interval includes the possibility of both a reduced and increased death rate (moderate-certainty evidence, downgraded for bias). The number of events was 51 per 1000 in the control group and 59 per 1000 in the group with mobility training (RR 1.16, 95% CI 0.64 to 2.10; 6 studies, 747 participants) (absolute improvement of 1% (6% more to 2% fewer)).

AUTHORS' CONCLUSIONS

The data in the review supports the use of mobility training for improving mobility in a frail community-dwelling older population. High-certainty evidence shows that compared to control, mobility training improves the level of mobility, and moderate-certainty evidence shows it may improve the level of functioning in frail community-dwelling older people. There is moderate-certainty evidence that the improvement in mobility continues six months post-intervention. Mobility training may make little to no difference to the number of people who fall or are admitted to nursing care facilities, or to the death rate. We are unsure of the effect on adverse events as the certainty of evidence was very low.

Interventions for preventing falls in Parkinson's disease

BACKGROUND

Most people with Parkinson's disease (PD) experience at least one fall during the course of their disease. Several interventions designed to reduce falls have been studied. An up-to-date synthesis of evidence for interventions to reduce falls in people with PD will assist with informed decisions regarding fall-prevention interventions for people with PD.

OBJECTIVES

To assess the effects of interventions designed to reduce falls in people with PD.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, four other databases and two trials registers were searched on 16 July 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. We also conducted a top-up search on 13 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that aimed to reduce falls in people with PD and reported the effect on falls. We excluded interventions that aimed to reduce falls due to syncope.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review procedures. Primary outcomes were rate of falls and number of people who fell at least once. Secondary outcomes were the number of people sustaining one or more fall-related fractures, quality of life, adverse events and economic outcomes. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

This review includes 32 studies with 3370 participants randomised. We included 25 studies of exercise interventions (2700 participants), three studies of medication interventions (242 participants), one study of fall-prevention education (53 participants) and three studies of exercise plus education (375 participants). Overall, participants in the exercise trials and the exercise plus education trials had mild to moderate PD, while participants in the medication trials included those with more advanced disease. All studies had a high or unclear risk of bias in one or more items. Illustrative risks demonstrating the absolute impact of each intervention are presented in the summary of findings tables. Twelve studies compared exercise (all types) with a control intervention (an intervention not thought to reduce falls, such as usual care or sham exercise) in people with mild to moderate PD. Exercise probably reduces the rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.63 to 0.87; 1456 participants, 12 studies; moderate-certainty evidence). Exercise probably slightly reduces the number of people experiencing one or more falls by 10% (risk ratio (RR) 0.90, 95% CI 0.80 to 1.00; 932 participants, 9 studies; moderate-certainty evidence).  We are uncertain whether exercise makes little or no difference to the number of people experiencing one or more fall-related fractures (RR 0.57, 95% CI 0.28 to 1.17; 989 participants, 5 studies; very low-certainty evidence). Exercise may slightly improve health-related quality of life immediately following the intervention (standardised mean difference (SMD) -0.17, 95% CI -0.36 to 0.01; 951 participants, 5 studies; low-certainty evidence). We are uncertain whether exercise has an effect on adverse events or whether exercise is a cost-effective intervention for fall prevention. Three studies trialled a cholinesterase inhibitor (rivastigmine or donepezil). Cholinesterase inhibitors may reduce the rate of falls by 50% (RaR 0.50, 95% CI 0.44 to 0.58; 229 participants, 3 studies; low-certainty evidence). However, we are uncertain if this medication makes little or no difference to the number of people experiencing one or more falls (RR 1.01, 95% CI 0.90 to 1.14230 participants, 3 studies) and to health-related quality of life (EQ5D Thermometer mean difference (MD) 3.00, 95% CI -3.06 to 9.06; very low-certainty evidence). Cholinesterase inhibitors may increase the rate of non fall-related adverse events by 60% (RaR 1.60, 95% CI 1.28 to 2.01; 175 participants, 2 studies; low-certainty evidence). Most adverse events were mild and transient in nature.  No data was available regarding the cost-effectiveness of medication for fall prevention. We are uncertain of the effect of education compared to a control intervention on the number of people who fell at least once (RR 10.89, 95% CI 1.26 to 94.03; 53 participants, 1 study; very low-certainty evidence), and no data were available for the other outcomes of interest for this comparisonWe are also uncertain (very low-certainty evidence) whether exercise combined with education makes little or no difference to the number of falls (RaR 0.46, 95% CI 0.12 to 1.85; 320 participants, 2 studies), the number of people sustaining fall-related fractures (RR 1.45, 95% CI 0.40 to 5.32,320 participants, 2 studies), or health-related quality of life (PDQ39 MD 0.05, 95% CI -3.12 to 3.23, 305 participants, 2 studies). Exercise plus education may make little or no difference to the number of people experiencing one or more falls (RR 0.89, 95% CI 0.75 to 1.07; 352 participants, 3 studies; low-certainty evidence). We are uncertain whether exercise combined with education has an effect on adverse events or is a cost-effective intervention for fall prevention.  AUTHORS' CONCLUSIONS: Exercise interventions probably reduce the rate of falls, and probably slightly reduce the number of people falling in people with mild to moderate PD.  Cholinesterase inhibitors may reduce the rate of falls, but we are uncertain if they have an effect on the number of people falling. The decision to use these medications needs to be balanced against the risk of non fall-related adverse events, though these adverse events were predominantly mild or transient in nature. Further research in the form of large, high-quality RCTs are required to determine the relative impact of different types of exercise and different levels of supervision on falls, and how this could be influenced by disease severity. Further work is also needed to increase the certainty of the effects of medication and further explore falls prevention education interventions both delivered alone and in combination with exercise.

The effectiveness of rehabilitation interventions including outdoor mobility on older adults' physical activity, endurance, outdoor mobility and falls-related self-efficacy: systematic review and meta-analysis

Objective

To determine the effectiveness of community-based rehabilitation interventions which incorporate outdoor mobility on physical activity, endurance, outdoor mobility and falls-related self-efficacy in older adults.

Design

MEDLINE, Embase, CINAHL, PEDro and OpenGrey were searched systematically from inception to June 2021 for randomised controlled trials (RCTs) of community-based rehabilitation incorporating outdoor mobility on physical activity, endurance, outdoor mobility and/or falls-related self-efficacy in older adults. Duplicate screening, selection, extraction and appraisal were completed. Results were reported descriptively and with random-effects meta-analyses stratified by population (proactive [community-dwelling], reactive [illness/injury]).

Results

A total of 29 RCTs with 7,076 participants were identified (66% high bias for at least one domain). The outdoor mobility component was predominantly a walking programme with behaviour change. Rehabilitation for reactive populations increased physical activity (seven RCTs, 587 participants. Hedge’s g 1.32, 95% CI: 0.31, 2.32), endurance (four RCTs, 392 participants. Hedges g 0.24; 95% CI: 0.04, 0.44) and outdoor mobility (two RCTs with 663 participants. Go out as much as wanted, likelihood of a journey) at intervention end versus usual care. Where reported, effects were preserved at follow-up. One RCT indicated a benefit of rehabilitation for proactive populations on moderate-to-vigorous activity and outdoor mobility. No effect was noted for falls-related self-efficacy, or other outcomes following rehabilitation for proactive populations.

Conclusion

Reactive rehabilitation for older adults may include walking programmes with behaviour change techniques. Future research should address the potential benefit of a walking programme for proactive populations and address mobility-related anxiety as a barrier to outdoor mobility for both proactive and reactive populations.

The Effect of Therapeutic Exercise Interventions on Physical and Psychosocial Outcomes in Adults Aged 80 Years and Older: A Systematic Review and Meta-Analysis

This systematic review aimed to evaluate the effects of therapeutic exercise on physical and psychosocial outcomes in community-dwelling adults aged 80 years or older. Databases were searched from inception to July 8, 2020. Randomized controlled trials (RCTs) were screened by two reviewers who extracted data and assessed study quality. Sixteen RCTs (1,660 participants) were included. Compared to nonexercise controls there was no evidence of an effect of exercise on performance based (standardized mean differences: 0.58, 95% confidence interval: [-0.19, 1.36]; I2: 89%; six RCTs; 290 participants; very low-quality evidence) or self-reported physical function (standardized mean differences: 1.35, 95% confidence interval: [-0.78, 3.48]; I2: 96%; three RCTs; 280 participants; very low-quality evidence) at short-medium term follow-up. Four RCTs reporting psychosocial outcomes could not be combined in meta-analysis and reported varying results. Exercise appeared to reduce the risk of mortality during follow-up (risk ratio: 0.47, 95% confidence interval: [0.32, 0.70]; I2: 0.0%; six RCTs; 1,222 participants; low-quality evidence).

The immediate effect of a single whole-body vibration session on balance, skin sensation, and pain in patients with type 2 diabetic neuropathy

Purpose

Patients with diabetic neuropathy usually suffer from impaired balance, pain, and decreased sole-foot sensation. The present research was designed to appraise the relic of whole-body vibration (WBV) on balance, pain, and sole-foot sensation in diabetic neuropathy patients.

Methods

Present study was a single-blind randomized controlled clinical trial. Thirty-four patients with type 2 diabetic neuropathy were randomly divided into intervention groups (n=17) and control (n=17). The therapeutic program in the intervention group included standing on the platform of the WBV device, and in the control group included using the device in off mode. Dynamic balance (including overall, anterior-posterior, and medial-lateral stability indices) was measured using Biodex device, functional balance with timed up and go (TUG) test, pain using the visual analog scale (VAS), and sole-foot sensation of both feet with a monofilament. The outcomes were measured in both groups before and after the interventions.

Results

Sixteen people in each group were analyzed. Intra-group comparison showed a significant improvement in the mean pain (P = 0.000), functional balance (P = 0.011), right and left sole-foot sensation (P = 0.001), and overall (P = 0.000), anterior-posterior (P = 0.000) and medial-lateral (P = 0.000) stability indices for the intervention group in post-intervention compared to pre-intervention. However, changes in the control group were not statistically significant. Results of inter-group comparison indicated a significant improvement in all parameters in the intervention group, except for functional balance.

Conclusion

WBV can be effective in reducing pain and improving the sole-foot sensation and dynamic balance.

Interventions to reduce falls in hospitals: a systematic review and meta-analysis

BACKGROUND

Falls remain a common and debilitating problem in hospitals worldwide. The aim of this study was to investigate the effects of falls prevention interventions on falls rates and the risk of falling in hospital.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Hospitalised adults.

INTERVENTION

Prevention methods included staff and patient education, environmental modifications, assistive devices, policies and systems, rehabilitation, medication management and management of cognitive impairment. We evaluated single and multi-factorial approaches.

OUTCOME MEASURES

Falls rate ratios (rate ratio: RaR) and falls risk, as defined by the odds of being a faller in the intervention compared to control group (odds ratio: OR).

RESULTS

There were 43 studies that satisfied the systematic review criteria and 23 were included in meta-analyses. There was marked heterogeneity in intervention methods and study designs. The only intervention that yielded a significant result in the meta-analysis was education, with a reduction in falls rates (RaR = 0.70 [0.51-0.96], P = 0.03) and the odds of falling (OR = 0.62 [0.47-0.83], P = 0.001). The patient and staff education studies in the meta-analysis were of high quality on the GRADE tool. Individual trials in the systematic review showed evidence for clinician education, some multi-factorial interventions, select rehabilitation therapies, and systems, with low to moderate risk of bias.

CONCLUSION

Patient and staff education can reduce hospital falls. Multi-factorial interventions had a tendency towards producing a positive impact. Chair alarms, bed alarms, wearable sensors and use of scored risk assessment tools were not associated with significant fall reductions.

Researchers' Perspectives on Adverse Event Reporting in Resistance Training Trials: A Qualitative Study

The objectives of our study were to understand researchers' current practices and perspectives on adverse event (AE) reporting in clinical trials of resistance training (RT), and identify barriers and facilitators of AE reporting. We conducted web conference or telephone-based one-on-one semi-structured interviews with 14 researchers who have published RT studies in individuals with or without health conditions. We audio-recorded and transcribed the interviews, and analyzed data using the thematic framework method. Four themes were identified in the context of RT studies: 1) researchers lack guidance and/or motivation for rigorous AE reporting; 2) researchers who undertake AE reporting educate and value participants, use trained personnel, and implement standardized guidelines; 3) suboptimal implementation of existing AE reporting standards and the perception that available guidelines do not apply to exercise trials; and 4) acceptability and feasibility of an exercise-specific guide for AE reporting depends on its content and format. In conclusion, AE reporting methods in the field of exercise science do not align with best practice. Strategies to reduce inconsistent and suboptimal AE reporting in RT trials are urgently needed and could be based on the barriers and facilitators identified in this study.

Gap between risk factors and prevention strategies? A nationwide survey of fall prevention among medical and surgical patients

Aims

This study aimed to determine the extent to which nurses report assessing evidence‐based falls risk factors and implementing targeted prevention for medical and surgical patients in China.

Design

This study was a national online survey.

Methods

The respondents were registered nurses working in medical and surgical units in 662 Chinese hospitals. The data concerning the falls risk factor assessments and targeted interventions implemented by nurses were collected online by the Nursing Management Committee of the Chinese Nursing Association in China in 2019.

Results

In total, 68 527 valid questionnaires were returned (95.0%). In medical and surgical units, nurses were most likely to report assessing balance, mobility and strength (81.6%) and orthostatic hypotension (76.4%) in falls patients and least likely to report assessing continence (61.3%) and feet and footwear (55.8%). Ensuring the use of appropriate footwear (79.3%) and managing syncope, dizziness and vertigo (73.8%) were the most common multiple interventions, while managing postural hypotension (48.8%) and cognitive impairment (48.4%) was the least common. Nine falls risk factors with clearly matched multifactorial interventions were identified in medical and surgical units (68.2%–97.1%).

Conclusions

The implementation of multifactorial interventions in medical and surgical wards is inconsistent as reported by nurses in medical and surgical wards. Throughout China, nurses are generally concerned about falls risk factors and prevention for their patients; however, limited attention has been focused on continence, feet and footwear assessment and the management of cognitive impairment. Evidence‐based falls prevention should be further tailored to the specific risk factors of each patient.

Impact

Best practice guidelines for falls prevention in hospitals have been developed and published, and it is important for nurses to use these guidelines to guide practice. Our findings identify that in routine care, healthcare providers and hospitals can prevent falls.

If exercise is medicine, why don't we know the dose? An overview of systematic reviews assessing reporting quality of exercise interventions in health and disease

OBJECTIVE

To determine how well exercise interventions are reported in trials in health and disease.

DESIGN

Overview of systematic reviews.

DATA SOURCES

PubMed, EMBASE, CINAHL, SPORTDiscus and PsycINFO from inception until June 2021.

ELIGIBILITY CRITERIA

Reviews of any health condition were included if they primarily assessed quality of exercise intervention reporting using the Consensus on Exercise Reporting Template (CERT) or the Template for Intervention Description and Replication (TIDieR). We assessed review quality using a modified version of A MeaSurement Tool to Assess systematic Reviews.

RESULTS

We identified 7804 studies and included 28 systematic reviews. The median (IQR) percentage of CERT and TIDieR items appropriately reported was 24% (19%) and 49% (33%), respectively. TIDieR items 1, Brief name (median=100%, IQR 4) and 2, Why (median=98%, IQR 6), as well as CERT item 4, Supervision and delivery (median=68%, IQR 89), were the best reported. For replication of exercise interventions, TIDieR item 8, When and how much, was moderately well reported (median=62%, IQR 68) although CERT item 8, Description of each exercise to enable replication (median=23%, IQR 44) and item 13, Detailed description of the exercise intervention (median=24%, IQR 66) were poorly reported. Quality of systematic reviews ranged from moderate to critically low quality.

CONCLUSION

Exercise interventions are poorly reported across a range of health conditions. If exercise is medicine, then how it is prescribed and delivered is unclear, potentially limiting its translation from research to practice.

PROSPERO REGISTRATION NUMBER

CRD42021261285; Open Science Framework: osf.io/my3ec/.

Effectiveness of a 12-Week Multi-Component Training Program with and without Transcranial Direct-Current Stimulation (tDCS) on Balance to Prevent Falls in Community-Dwelling Older Adults: A Study Protocol

Simple Summary

Falls in community-dwelling individuals aged over 65 produce serious outcomes such as disability, morbidity, and mortality, as well as high healthcare costs. This research aims to assess whether a multicomponent training programme (McTP) combined with a transcranial direct-current stimulation device (tDCS), Halo Sport, produces improvements in balance and other gait-related parameters. Therefore, this study intends to test the efficacy of adding a tCDS device to an McTP in order to prevent falls in older adults by testing the safety, efficacy, and effectiveness of its implementation in care resources for the elderly.

Abstract

Approximately one-third of elderly people aged over 65 who live in the community experience falls every year, with the proportion increasing with age. Moreover, of those who fall, about half will fall again in the following year. The falls’ consequences include disability, morbidity, and mortality. Although many external and internal factors lead to falls, balance issues play a major role. Multi-component training programs (McTP) usually combine balance, strength, cardiorespiratory fitness, and flexibility, with studies reporting multiple benefits on the health-related quality of life. Halo Sport is a transcranial direct-current stimulation (tDCS) device with promising results for gait performance. This study aims to test the effectiveness of the introduction of a tCDS device to an McTP to prevent falls in older adults. The sample will consist of 46 people aged 65 years or older, randomly assigned to experimental (n = 23) and control (n = 23) groups. The experimental group will perform the McTP while wearing tDCS, and the control group will perform McTP without the device, for three sessions per week over 12 weeks. The main measures will provide information about (1) safety, (2) applicability, (3) balance, (4) number of falls, (5) physical fitness, (6) risk of falling, (7) fear of falling, (8) health-related quality of life, and (9) cognitive function. Among the practical implications of this program, it is intended to provide data on its safety and effectiveness to be implemented in different resources as a tool for the prevention of falls.

Effects of Resistance Training on Motor- and Non-Motor Symptoms in Patients with Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Previous reviews indicated positive effects of resistance training (RT) on motor outcomes in Parkinson's disease (PD). However, inconsistencies between the included studies exist, and non-motor outcomes have only scarcely been considered in a review on RT in PD.

OBJECTIVE

To analyze the RT effects on motor- and non-motor outcomes in PD patients compared to passive and physically active control groups (i.e., other structured physical interventions).

METHODS

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL for randomized controlled trials of RT in PD. After identifying 18 studies, a meta-analysis was conducted for the outcomes muscle strength, motor impairment, freezing of gait (FoG), mobility and balance, quality of life (QoL), depression, cognition, and adverse events. Meta-analyses with random models were calculated using mean differences (MD) or standardized mean differences (SMD) with 95% confidence intervals (CI).

RESULTS

When comparing RT with passive control groups, the meta-analyses showed significant large effects on muscle strength (SMD = -0.84, 95% CI -1.29--0.39, p = 0.0003), motor impairment (SMD = -0.81, 95% CI -1.34--0.27, p = 0.003), mobility and balance (MD = -1.81, 95% CI -3.13--0.49, p = 0.007), and small significant effects on QoL (SMD = -0.48, 95% CI -0.86--0.10, p = 0.01). RT compared with physically active control groups reached no significant results for any outcome.

CONCLUSIONS

RT improves muscle strength, motor impairment, mobility and balance, QoL, and depression in PD patients. However, it is not superior to other physically active interventions. Therefore, exercise is important for PD patients but according to this analysis, its type is of secondary interest.

[Evidence of Physical Training Programs for Fall Prevention in Seniors]

Evidence of Physical Training Programs for Fall Prevention in Seniors Abstract. It has been shown that physical exercise reduced fall risk by 23-42% in community-dwelling adults aged 65+. This is particularly true for physical exercises with functional, balance and strength components. Growing evidence shows that functional training is particularly effective in reducing fall risk. Functional training is composed by exercises which reflect activities of daily life, supported by weights and other aids.

Fall prevention in community-dwelling adults with mild to moderate cognitive impairment: a systematic review and meta-analysis

BACKGROUND

Cognitive impairment (CI) increases an individual's risk of falls due to the role cognition plays in gait control. Older adults with dementia fall 2-3 times more than cognitively healthy older adults and 60-80% of people with dementia fall annually. Practitioners require evidence-based fall prevention best practices to reduce the risk of falls in cognitively impaired adults living in the community.

METHODS

We conducted a systematic review and meta-analysis to identify the effectiveness of primary and secondary fall prevention interventions in reducing falls and fear of falling, and improving gait, balance, and functional mobility. We searched 7 databases for fall prevention interventions involving community-dwelling adults ≥50 years with mild to moderate CI. Reviewers screened citations, extracted data, and assessed risk of bias and certainty of evidence (GRADE). We assessed statistical and methodological heterogeneity and performed a meta-analysis of studies including subgroup analysis based on intervention and risk of bias groupings.

RESULTS

Five hundred nine community-dwelling adults (mean age 67.5 to 84.0 years) with mild to moderate CI from 12 randomized or clinical controlled trials (RCTs/CCTs) were included in this review. Eight studies were exercise interventions, 3 were multifactorial, and 1 provided medication treatment. Fall prevention interventions had significant effects of medium magnitude on fear of falling (standardized mean difference (SMD) -0.73 [- 1.10, - 0.36]), balance (SMD 0.66 [0.19, 1.12]), and functional mobility measured as Timed Up and Go test (SMD -0.56 [- 0.94, - 0.17]) and significant effects of small magnitude on gait control (SMD 0.26 [0.08, 0.43]) all with moderate certainty of evidence. The meta-analysis showed no significant effects for falls (number of events or falls incidence). Sub-analysis showed that exercise and low risk of bias studies remained significant for balance and perceived risk of falls.

CONCLUSION

The effect of fall prevention interventions on direct outcomes, such as falls, remains unclear in cognitively impaired individuals. Exercise interventions are effective at improving fall risk factors, however, high quality studies with longer follow-up and adequate sample sizes are needed to determine their effectiveness on falls directly. There remains a gap in terms of effective fall prevention interventions for older adults with CI.

A five-year prospective evaluation of anticholinergic cognitive burden and falls in the Malaysian elders longitudinal research (MELoR) study

BACKGROUND

While anticholinergic use is associated with stroke, dementia and mortality, few have evaluated its potential link with falls. To determine the relationship between anticholinergic cognitive burden (ACB) and falls over five years using the Malaysian Elders Longitudinal Research (MELoR).

METHODS

Community-dwelling adults aged 55 years and over were recruited through electoral roll sampling. Data obtained at baseline and follow-up (FU) at two and five years were included. Falls in the preceding 12 months were recorded.

RESULTS

Of the 1499 individuals (mean (SD) age= 68.9(7.5) yrs and 53.3% female) with information on baseline ACB exposure, 575(38.4%) had ACB scores of 1-2 and 117(7.8%) had ACB scores ≥3. Differences in age, ethnicity, smoking status, diabetes, hypertension, cardiovascular disease, arthritis and education existed between ACB groups. Fall occurrence differed between ACB groups at recruitment (p = 0.004) and 2-year FU (p = 0.001) but not at 5-year FU (p = 0.053). Logistic regression revealed an independent association between ACB 1-2 and falls at baseline (odds ratio, OR (95% confidence interval, CI) =1.412(1.035-1.926)) and ACB≥3 and falls at 2-yr FU (OR (95%CI) =2.098(1.032-4.263)) following adjustment for confounders.

CONCLUSION

Low level exposure to drugs with anticholinergic properties was associated cross-sectionally with falls, while exposure to higher levels were prospectively associated with falls at 2-year but not at 5-year FU. Future studies should determine whether avoidance of drugs with anticholinergic effects will lead to reduction in falls.

Health technologies for the prevention and detection of falls in adult hospital inpatients: a scoping review

OBJECTIVE

The objective of this scoping review was to examine and map the evidence relating to the reporting and evaluation of technologies for the prevention and detection of falls in adult hospital inpatients.

INTRODUCTION

Falls are a common cause of accidental injury, leading to significant safety issues in hospitals globally, and resulting in substantial human and economic costs. Previous research has focused on community settings with less emphasis on hospital settings.

INCLUSION CRITERIA

Participants included adult inpatients, aged 18 years and over; the concept included the use of fall-prevention or fall-detection technologies; the context included any hospital ward setting.

METHODS

This scoping review was conducted according to JBI methodology for scoping reviews, guided by an a priori protocol. A wide selection of databases including MEDLINE, CINAHL, AMED, Embase, PEDro, Epistimonikos, and Science Direct were searched for records from inception to October 2019. Other sources included gray literature, trial registers, government health department websites, and websites of professional bodies. Only studies in the English language were included. A three-step search strategy was employed, with all records exported for subsequent title and abstract screening prior to full-text screening. Screening was performed by two independent reviewers and data extraction by one reviewer following agreement checks. Data are presented in narrative and tabular form.

RESULTS

Over 13,000 records were identified with 404 included in the scoping review: 336 reported on fall-prevention technologies, 51 targeted detection, and 17 concerned both. The largest contributions of studies came from the USA (n=185), Australia (n=65), the UK (n=36), and Canada (n=18). There was a variety of study designs including 77 prospective cohort studies, 33 before-after studies, and 35 systematic reviews; however, relatively few randomized controlled trials were conducted (n = 25). The majority of records reported on multifactorial and multicomponent technologies (n = 178), followed by fall detection devices (n = 86). Few studies reported on the following interventions in isolation: fall risk assessment (n = 6), environment design (n = 8), sitters (n = 5), rounding (n = 3), exercise (n = 3), medical/pharmaceutical (n = 2), physiotherapy (n = 1), and nutritional (n = 1). The majority (57%) of studies reported clinical effectiveness outcomes, with smaller numbers (14%) reporting feasibility and/or acceptability outcomes, or cost-effectiveness outcomes (5%).

CONCLUSIONS

This review has mapped the literature on fall-prevention and fall-detection technology and outcomes for adults in the hospital setting. Despite the volume of available literature, there remains a need for further high-quality research on fall-prevention and fall-detection technologies.

Nurses' view of implementation evidence-based fall prevention interventions: A qualitative study

AIM

The purpose of this descriptive qualitative study was to evaluate nurses' views of implementation evidence-based fall prevention interventions.

METHODS

The study was conducted with participation of nurses who worked in a training and research hospital after evidence-based fall prevention interventions had been implemented. Interviews were done with 17 nurses who participated in all training courses.

RESULTS

The evaluation of the interventions was examined, and three themes were extracted through analysis: 'effectiveness of training programme', 'barriers' and 'suggestions'.

CONCLUSION

Nurses emphasized that evidence-based fall prevention interventions are usable in hospital, but team collaboration and administrative support are required for better outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

The study result shows that fall prevention interventions should be introduced to all health care professionals, through the use of various training methods. Training should be given to patients and their caregivers, and barriers that nurses stated like understaffing, lack of materials and tools that ensure patient safety and internet (research/scientific information) access restriction should be reduced.

Effective, sustainable, and transferable physical exercise interventions for fall prevention among older people

INTRODUCTION

Falls among older people are preventable through exercise-based programs. However, scientific evidence must be translated into practice to support professionals who implement such programs.

AIM

This study aimed to identify physical exercise interventions for fall prevention and to determine the best practice for implementing them in local community-dwelling older adults.

METHOD

We used a narrative synthesis method to produce Effective, Sustainable, and Transferable Preventive Interventions. We reviewed guidelines, systematic reviews, and randomized controlled trials (RCT) to find the best evidence supporting physical exercises to prevent falls, followed by discussing the evidence with clinical experts to evaluate the best strategy for implementing them into the local context. These steps resulted in the development of a user manual.

RESULTS

We included two guidelines, one systematic review with a meta-analysis, and one RCT. The developed draft manual includes activities, methods, infrastructural resources, human capital, stakeholders, frequency, and duration of the intervention, information, and educational materials, and implementation models. Our discussion of the intervention with a panel of experts considered resources, barriers, and similar experiences to ensure effectiveness and economic, social, and time sustainability.

CONCLUSION

The developed manual could be implemented in the local context and adapted to the needs of the population while considering available resources.

Applying the RE-AIM implementation framework to evaluate fall prevention interventions in community dwelling adults with cognitive impairment: a review and secondary analysis

BACKGROUND

Cognitive impairment (CI) is a risk factor for falls due to environmental or living settings, balance, gait and vision impairments, as well as medications. While previous systematic reviews have focused on the effectiveness of fall prevention programs in adults with cognitive impairment, very limited information is available on their implementation. This review examines what aspects of fall prevention interventions for community-dwelling adults with CI have been reported using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to support successful implementation.

METHODS

We examined the included studies from our systematic review, which searched 7 databases for primary and secondary fall prevention interventions involving community-dwelling adults ≥50 years with mild to moderate CI. Reviewers screened citations and extracted data for study characteristics and the 5 dimensions (62 criteria) of the RE-AIM framework.

RESULTS

Twelve randomized or clinical controlled trials (RCTs/CCTs) consisting of 8 exercise interventions, 3 multifactorial interventions, and 1 medication treatment were included in the review. Only 4 of 62 criteria were reported by all 12 included studies and 29 criteria were not reported by any of the studies. Five of the included studies reported on 20 or more of the 62 possible RE-AIM criteria and 3 of these studies self-identified as "feasibility" studies. While Reach was the best-reported construct by the included studies, followed by Effectiveness and Implementation, the criteria within the Adoption and Maintenance constructs were rarely mentioned by these studies. In general, there was also wide variation in how each of the criteria were reported on by study authors.

CONCLUSION

Based on the reporting of RE-AIM components in this review, we are unable to make connections to successful intervention components and thus practice-based recommendations for fall prevention in those with CI. The lack of detail regarding implementation approaches greatly limits the interpretation and comparisons across studies to fully inform future research efforts.

The effectiveness of physical exercise type and length to prevent falls in nursing homes: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to determine the effect of physical exercise on fall prevention and the characteristics required for effective exercise.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

METHOD

Six databases (PubMed, Cochrane Library, Web of Science, Excerpta Medica Database, SinoMed and China National Knowledge Infrastructure) were searched to find the relevant randomised controlled trials published before January 2021. The study was reported in compliance with PRISMA statement. The included studies were assessed for quality using the Cochrane "Risk of Bias" assessment tool, and the data were analysed with review manager.

RESULTS

Overall, fourteen studies were included. Compared physical exercise with normal daily life, the pooled effect size of all trials indicated that intervention had significant effect on fall prevention (RR = 0.85, 95% CI = 0.73-0.98). The result of subgroup revealed that long-term exercise and balance exercise could reduce falling, while short-term exercise and more complex exercise couldn't.

CONCLUSIONS

Exercise may be effective in reducing falls, and long-term balance exercise played a role in preventing falls in nursing homes.

Cost-Effectiveness of an Exercise Programme That Provided Group or Individual Training to Reduce the Fall Risk in Healthy Community-Dwelling People Aged 65-80: A Secondary Data Analysis

Research has demonstrated that some exercise programs are effective for reducing fall rates in community-dwelling older people; however, the literature is limited in providing clear recommendations of individual or group training as a result of economic evaluation. The objective of this study was to assess the cost-effectiveness of the Otago Exercise Program (OEP) for reducing the fall risk in healthy, non-institutionalized older people. An economic evaluation of a multicenter, blinded, randomized, non-inferiority clinical trial was performed on 498 patients aged over 65 in primary care. Participants were randomly allocated to the treatment or control arms, and group or individual training. The program was delivered in primary healthcare settings and comprised five initial sessions, ongoing encouragement and support to exercise at home, and a reinforcement session after six months. Our hypothesis was that the patients who received the intervention would achieve better health outcomes and therefore need lower healthcare resources during the follow-up, thus, lower healthcare costs. The primary outcome was the incremental cost-effectiveness ratio, which used the timed up and go test results as an effective measure for preventing falls. The secondary outcomes included differently validated tools that assessed the fall risk. The cost per patient was USD 51.28 lower for the group than the individual sessions in the control group, and the fall risk was 10% lower when exercises had a group delivery. The OEP program delivered in a group manner was superior to the individual method. We observed slight differences in the incremental cost estimations when using different tools to assess the risk of fall, but all of them indicated the dominance of the intervention group. The OEP group sessions were more cost-effective than the individual sessions, and the fall risk was 10% lower.

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

OBJECTIVES

To establish the evidence for rehabilitation interventions tested in populations of patients admitted to ICU and critical care with severe respiratory illness, and consider whether the evidence is generalizable to patients with COVID-19.

METHODS

The authors undertook a rapid systematic review. Medline (via OvidSP), CINAHL Complete (via EBSCOhost), Cochrane Library, Cochrane Database of Systematic Reviews and CENTRAL (via Wiley), Epistemonikos (via Epistemonikos.org), PEDro (via pedro.org.au) and OTseeker (via otseeker.com) searched to 7 May 2020. The authors included systematic reviews, RCTs and qualitative studies involving adults with respiratory illness requiring intensive care who received rehabilitation to enhance or restore resulting physical impairments or function. Data were extracted by one author and checked by a second. TIDier was used to guide intervention descriptions. Study quality was assessed using Critical Skills Appraisal Programme (CASP) tools.

RESULTS

Six thousand nine hundred and three titles and abstracts were screened; 24 systematic reviews, 11 RCTs and eight qualitative studies were included. Progressive exercise programmes, early mobilisation and multicomponent interventions delivered in ICU can improve functional independence. Nutritional supplementation in addition to rehabilitation in post-ICU hospital settings may improve performance of activities of daily living. The evidence for rehabilitation after discharge from hospital following an ICU admission is inconclusive. Those receiving rehabilitation valued it, engendering hope and confidence.

CONCLUSIONS

Exercise, early mobilisation and multicomponent programmes may improve recovery following ICU admission for severe respiratory illness that could be generalizable to those with COVID-19. Rehabilitation interventions can bring hope and confidence to individuals but there is a need for an individualised approach and the use of behaviour change strategies. Further research is needed in post-ICU settings and with those who have COVID-19. Registration: Open Science Framework https://osf.io/prc2y.