Setting-related influences on physical inactivity of older adults in residential care settings: a review

Qualitative Comparative Analysis of exercise interventions for fall prevention in residential aged care facilities

BACKGROUND

Exercise interventions are highly effective at preventing falls in older people living in the community. In residential aged care facilities (RACFs), however, the evidence for effectiveness is highly variable, warranting exploration of drivers of successful trials. This study aims to identify the conditions of randomised controlled trials (RCTs) that are associated with reducing falls in RACFs and test whether it can explain the variability.

METHODS

RCTs testing exercise interventions in RACFs compared to usual care, reporting rate or risk of falls from the 2018 Cochrane Collaboration review and a search update to December 2022 were included. Two authors independently extracted and coded trial conditions and outcomes according to a theory developed from prior Intervention Component Analysis. Trial outcomes were coded as successful or unsuccessful based on point estimates for the rate or risk ratio for falls, or p value. Qualitative Comparative Analysis (QCA), utilising Boolean minimisation theory, was conducted to determine the key conditions driving trial success. A subgroup meta-analysis and the GRADE approach was applied to the final theory.

RESULTS

Eighteen trials undertaken in 11 countries with 2,287 residents were included. Participants were predominately ambulant females aged 70 to 80 with cognitive impairment. Most interventions were fully supervised or supervised at the start of the intervention. QCA identified two configurations as drivers of successful exercise falls prevention programs: (i) group exercise that is moderate or low intensity, or (ii) for independent ambulatory residents, exercise for more than 1 h per week. The combination of configuration (i) and (ii) had consistency and total coverage scores of 1, indicating all trials were explained. This combination was associated with a reduction in falls (rate ratio 0.45, 95%CI 0.34 to 0.59; risk ratio 0.66, 95%CI 0.53 to 0.82; low certainty evidence).

CONCLUSION

To successfully reduce falls in RACFs, exercise programs should provide continuous supervised moderate-intensity group exercise. For programs that mostly include independent ambulatory residents, exercise for at least 80 min per week should be provided. As many current residents are frail, tailored exercise is likely necessary and an individualised dose may be required. Future trials should test exercise interventions for less mobile residents.

The effectiveness of structured physical activity on agitation in people with dementia: a rapid review

OBJECTIVES

Managing agitation and other behaviours that challenge is a significant dementia care challenge. The priority is to find effective non-pharmacological interventions as drug treatments can have significant side effects. This review evaluates the effectiveness of structured physical activity on agitation in dementia.

METHOD

Our rapid review searched four electronic databases, Cochrane CENTRAL, MEDLINE, CINAHL and Embase, for interventional studies using a structured physical activity programme in people with dementia and studied the effect of this activity on behaviours that challenge. Study quality was assessed using CASP criteria and data was narratively synthesised.

RESULTS

We included 13 studies in this review (four rated as high quality), involving a total of 1546 participants. Results were analysed according to exercise type, frequency and intensity of the intervention. Exercise is effective in reducing agitation and studies with higher adherence to exercise demonstrated more positive effects on agitation and behaviours that challenge.

CONCLUSION

Physical activity can be effective in reducing agitation in older adults with dementia. Further research is needed to clarify the type of intervention that is most beneficial. Strategies to make physical activity more acceptable and available to people with dementia need to be established.

The Role of the Built Environment in Supporting Older Adults' Engagement: A Narrative Literature Review

OBJECTIVE

This literature review aimed to summarize the existing knowledge surrounding the role of the built environment in supporting older adults' physical and social engagement and identify opportunities for future research and design that facilitates older adults' engagement at multiple environmental scales: from interior spaces to neighborhoods.

BACKGROUND

Physical environments can support or impede older adults' physical and social engagement: willful, motivated involvement in meaningful activity or occupation. Research shows that engagement is a core component of health and well-being and relates to positive health outcomes, including reduced disease risk, better mental health, and improved physical and cognitive function. Thus, designing supportive built environments for engagement can yield significant, positive health and well-being impacts.

METHODS

A systematized search of five databases, a hand search, and an iterative screening process identified 55 studies for inclusion in this review. Through inductive thematic analysis, this review summarizes findings regarding the built environment's role in physical and social engagement in older age and design strategies to facilitate engagement and support health and well-being.

RESULTS

Evidence indicates that built environment characteristics can influence older people's physical and social engagement in homes, neighborhoods, and care settings. The thematic analysis of the included studies identified three key themes concerning the relationships of built environment characteristics to older adults' engagement across multiple environmental scales: connection, access, and security.

CONCLUSIONS

Built environments influence older people's physical and social engagement, significantly affecting their health, well-being, abilities, and longevity. Numerous design strategies can support older adults' engagement, but more research is needed.

Training effects of set- and repetition-interval rest time on recumbent-boxing exercise: Could virtual reality improve further?

This study examined the influence of set-interval and repetition-interval rest time of virtual reality (VR) boxing game in supine-lying posture. Fifty healthy middle-aged adults were randomly assigned into VR and non-VR groups to perform six different exercise protocols with varying set-interval and repetition-interval rest times (S0R0, S0R1/3, S0R2/3, S40R0, S40R1/3, and S40R2/3). Analysis on the non-VR group showed significant differences between exercise protocols for average heart rate (p < 0.001), maximum ventilation volume (p < 0.001), respiratory quotient (p < 0.001), oxygen pulse (p < 0.001), and excess post-exercise oxygen consumption (EPOC) (p = 0.003). VR appeared to have no further improvement on physical training effects in middle-aged adults, while the participants reported negative experience that might be associated with the over-exertion. Future study might need to explore game design elements that can accommodate high-exertion exercises.

Relationships between Physical Activity and Selected Chronic Diseases among Functionally Independent Long-Term Care Residents during the Post-Lockdown Period in Croatia

The aim of this observational study was to investigate the level and association of physical activity and selected chronic diseases in functionally independent LTC residents after prolonged physical and social isolation during COVID-19 in Croatia. Adhering to the inclusion criteria, 180 functionally independent residents were included in the study. Assessment of physical activity was carried out by 7-day motor monitoring. Prolonged physical and social isolation negatively affected the achieved level of physical activity of LTC residents (x¯ = 5058.74). Major depressive disorder resulted in significantly lower residents' physical activity scores, demonstrating a shrinking effect ranging from 0.42 to 0.45. A significant negative impact on the residents' physical activity was also found in the presence of osteoarthritis and iron deficiency anemia, where a downward effect was present in the range from 0.66-0.72 and 0.64 to 0.66. The presence of comorbidities has a significant negative impact on the residents' physical activity, where a downward effect is present in the range from 0.91-0.92.

Prevalence of sleep disturbances in people with dementia living in the community: A systematic review and meta-analysis

This study aimed to systematically review and meta-analyse the prevalence of sleep disturbances in people with dementia and examine demographic predictors and whether overall prevalence has changed over time. We searched Embase, MEDLINE and PsycINFO for studies reporting the prevalence of sleep disturbances in people with dementia living at home. We meta-analysed the data and calculated the pooled prevalence of sleep disturbances in people with dementia overall and in dementia subtypes. We used meta-regressions to investigate the effects of study characteristics, publication dates and participant demographics. Eleven studies fulfilled the inclusion criteria. The pooled prevalence of any symptoms of sleep disturbance was 26 % (95 % confidence intervals, CI: 23-30 %; n = 2719) and of clinically significant sleep disturbance 19 % (13-25 %; n = 2753). The pooled prevalence of sleep disturbance symptoms was significantly lower among people with Alzheimer's disease (24 %; 16-33 %, n = 310) than Lewy body dementia (49 %; 37-61 %, n = 65). Meta-regression analysis did not find that publication year, participant's age, sex and study quality predicted prevalence. Sleep disturbances are common among people with dementia living in the community, especially in Lewy body dementia. There was no change in prevalence according to publication dates, suggesting treatment has not improved over time.

Physical Activity in People With Dementia Living in Long-Term Care Facilities and the Connection With Environmental Factors and Behavior

This study is conducted in order to gain a better understanding of the relationship between physical activity and agitated behavior among older people with dementia, and physical activity and characteristics of long-term care wards. Data were collected among people with dementia living in long-term care facilities (N = 76) by conducting observations at the wards and distributing questionnaires among professional caregivers. The results show that participants are largely inactive (82.8%) and a significant relation was found between the degree of physical activity and characteristics of the ward such as "taking sufficient time," which relates to the time caregivers take when interacting with residents. This study supports the existing knowledge about the degree of physical activity among people with dementia in long-term care and adds information about the potential influence of organizational factors that could be valuable for daily practice.

''We usually choose safety over freedom'': results from focus groups with professional caregivers in long-term dementia care

Background

People with dementia living in nursing homes are mostly sedentary, which is a consequence of various personal, environmental and organizational factors. Until now, studies on physical activity and safety in dementia have focused on residents and caregivers from the viewpoint of (individual) care provision and health benefits. There has been little to no focus on the possible influence of group dynamics between care providers with regard to physical activity and safety. The aim of this study is to gain more insight into the viewpoints and intentions of groups of professional caregivers towards safety and physical activity and the potential influence of the group-oriented setting in long-term care on physical activity of individual residents.

Methods

A qualitative study comprising three focus group discussions including professional caregivers (n = 15) was conducted within two long-term care organizations in the Netherlands. Focus group discussions were structured using an interview guide derived from a preliminary framework, based on existing literature and complemented with clinical expertise.

Results

Seven themes could be derived from the focus group discussions that influence physical activity and safety: 1) Individual health and abilities; 2) Balancing physical activity and safety; 3) Physical restraints; 4) Group interests versus the individual interests; 5) Organization of care and physical environment; 6) Perceived responsibilities and tasks of professional caregivers and 7) Change is challenging.

Conclusions

Due to multiple influencing factors, the balance for care providers in long-term care generally tends towards safety over physical activity. Furthermore, in order to stimulate physical activity various limitations are experienced, including the organization of care, the general health of the residents and difficulty to achieve changes in daily care. Most importantly, the group interests of both the professional caregivers and the residents have a substantial influence on the incorporation of physical activity in daily care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07952-0.

Evaluating physical environments for older people-Validation of the Swedish version of the Sheffield Care Environment Assessment Matrix for use in Finnish long-term care

AIM

To validate a Finnish version of the Sheffield Care Environment Assessment Matrix (S-SCEAM) instrument for assessing the physical environment of long-term care settings and to describe the current status of the environmental quality of long-term care settings for older people in Finland.

BACKGROUND

The importance of providing a well-designed physical environment for older people is supported by the research literature. There is limited research of the physical environments of long-term care settings from the perspective of nursing science and nor is there much research into the instruments for assessing them.

DESIGN

A descriptive, correlational and observational study.

METHODS

Forward and back translation process was used followed by structured observations with S-SCEAM-Fin in 20 long-term care units in intensive residential care facilities for older people with 24-h nursing assistance and with extensive support for daily activities. Spearman's rho correlation, Cohen's kappa, percentage of agreement and Kuder-Richardson formula coefficients were calculated to assess psychometric properties of the translated S-SCEAM-Fin. S-SCEAM-Fin standardised scores were calculated to describe the current status of the environmental quality.

RESULTS

Inter-scale (domain) correlations showed low to moderate correlations between the domains. Consistency was acceptable in four of the domains. Cohen's kappa values indicated good (0.796 and 0.648) intra-rater and inter-rater (0.910 and 0.553) reliability. The overall mean of the standardised scores was 57.00, but there was variation between domains. Small units received the highest scores in the six domains.

CONCLUSIONS

S-SCEAM-Fin was useful in assessing environmental quality. Assessment of the environmental quality disclosed deficiencies in ensuring settings adequate for older people.

IMPLICATIONS FOR PRACTICE

The increasing numbers of older people with health conditions are residing in long-term care settings. It is essential to create supportive physical environments. The instrument can be useful when planning new facilities or proposing new recommendations for institutional living environments.

'All We Have to Decide Is What to Do with the Time That Is Given to Us' a Photovoice Study on Physical Activity in Nursing Homes

(1) Background: Despite high prevalence of physical inactivity and sedentariness among nursing home residents, research on the influence of environments on this topic remains scarce. This Photovoice study explores how structural and social environments relate to residents’ everyday physical activity (PA). (2) Methods: 27 residents, staff, and significant others conducted Photovoice in eight nursing homes in Germany to document factors facilitating or hindering PA. Photographs were discussed with the participants in eight focus groups and analysed using thematic analysis. (3) Results: 169 photographs (between 8 and 42per home) were categorized into three thematic groups: (1) ‘architectural challenges for PA promotion in nursing homes’; (2) ‘opportunities and limitations of using daily work equipment for PA promotion’; (3) ‘social incentives for PA promotion’. Photographs’ foci in the homes differed considerably between participant groups. Staff primarily chose environmental constructions and aids that they perceived to enable residents’ PA. Residents were more likely to express affections and emotions that would encourage them to be active. (4) Conclusions: PA promotion research in this setting should be sensitive to diverse perceptions of different stakeholder groups and existing power imbalances. Interventions are needed that integrate residents’ needs and train staff on how to consider residents’ perspectives.

The Homestead: Developing a Conceptual Framework through Co-Creation for Innovating Long-Term Dementia Care Environments

Alternative care environments for regular nursing homes are highly warranted to promote health and well-being of residents with dementia that are part of an age-friendly and dementia-friendly city and society. Insight is lacking on how to translate evidence-based knowledge from theory into a congruent conceptual model for innovation in current practice. This study reports on the co-creation of an alternative nursing home model in the Netherlands. A participatory research approach was used to co-create a conceptual framework with researchers, practitioners and older people following an iterative process. Results indicate that achieving positive outcomes for people with dementia, (in)formal caregivers, and the community is dependent on how well the physical, social and organizational environment are congruently designed. The theoretical underpinnings of the conceptual model have been translated into "the homestead," which is conceptualized around three main pillars: activation, freedom and relationships. The Homestead Care Model is an illustrative example of how residential care facilities can support the development of age-friendly communities that take into consideration the needs and requirements of older citizens. However, challenges remain to implement radical changes within residential care. More research is needed into the actual implementation of the Homestead Care Model.

Facilitators and Barriers to Attendance in a Nursing Home Exercise Program

Women and residents in Certified Nursing Homes (CNHs) with higher star ratings had better attendance in exercise and social engagement programming (ie, Bingocize) than men and residents in CNHs with lower ratings.

OBJECTIVE

The purpose of the current study was to determine whether resident factors and nursing home star ratings influenced attendance in Bingocize, a therapeutic exercise program that incorporates opportunities for social engagement in nursing homes.

DESIGN

This is a descriptive study of data collected across multiple nursing homes over 17 months.

SETTING AND PARTICIPANTS

Data were collected from residents in 25 certified nursing homes in the mid-southern United States.

METHODS

The program consisted of two 45-60-minute sessions each week. Bingocize attendance was recoded as number of sessions attended each month from September 2017 to February 2019 in 25 nursing homes. The impact of gender, age, cognitive functioning, and Nursing Home Star Ratings on adherence to the program based on percentage of Bingocize sessions attended was analyzed.

RESULTS

A total of 1165 residents of certified nursing homes were recruited and participated in Bingocize; 55% of participants attended Bingocize infrequently or had poor attendance, 21% of the participants had average attendance, and 24% had good attendance. The association between gender and level of attendance was significant (P = .045). The star rating of the nursing home also affected attendance. As star level of the nursing home increased, the percentage of good attendance increased (P < .001): 19.12% (1 star), 20.69% (2 stars), 23.57% (3 stars), 33.76% (4 stars), and 36.63% (5 stars). Neither age nor cognitive functioning [based on Brief Interview of Mental Status (BIMS)] had a significant impact on attendance.

CONCLUSIONS AND IMPLICATIONS

We examined adherence to an exercise program called Bingocize based on percentage of sessions attended in 25 nursing homes. Women and residents in nursing homes with higher star ratings were reported to have better attendance in Bingocize than men or residents in nursing homes with lower ratings, respectively. Residents of all ages and cognitive ability can successfully participate in the Bingocize program.

Nutritional Status Plays More Important Role in Determining Functional State in Older People Living in the Community than in Nursing Home Residents

The aim of this study was to verify whether the relationship between nutritional and functional status differs between seniors in the community and those in long-term care institutions. One hundred nursing home (NH) residents aged 60 years and above and 100 sex- and age-matched community-dwelling (CD) older adults were examined. Functional status was assessed using the Comprehensive Geriatric Assessment (CGA) and nutritional status using anthropometric measures, the Mini Nutritional Assessment questionnaire (MNA) and bioimpedance analysis (BIA). Significant environmental interactions were observed with resting metabolic rate (RMR), extracellular water (ECW) and intracellular water (ICW) ratio, skeletal muscle mass (SMM), skeletal muscle index (SMI) and impedance (Z) and resistance (R) to the results of the Timed Up and Go (TUG) test. The two groups demonstrated different relationships between Z and R and handgrip strength and between Geriatric Depression Scale (GDS) score and fat free mass (FFM), body density, total body water (TBW) and phase angle (PhA). Nutritional status seems to be more important for functional state in CD older people than in NH residents. Therefore, to ensure the functional independence of seniors living in the community, it is crucial to maintain the correct nutritional parameters. Further studies are necessary to account for the fact that this relationship is less significant among NH residents and to identify other factors that may contribute to these discrepancies between community and institutional environments.

Effects of Physical Exercises and Verbal Stimulation on the Functional Efficiency and Use of Free Time in an Older Population under Institutional Care: A Randomized Controlled Trial

Older people in institutional care are, for the most part, physically inactive and do not interact with each other or medical staff. Therefore, reducing sedentary behaviour is a new, important, and modifiable lifestyle variable that can improve the health of elderly people. The aim of the project was to assess the degree of improvement in functional performance and the possibility of changing habitual, free time behaviour among elderly people under institutional care by applying physical training with verbal stimulation. The study covered older people, aged 65–85 years, who are living a sedentary lifestyle in care homes in Southeastern Poland. Those who met the eligibility criteria were enrolled in the study and were assigned, at random, to one of four parallel groups: basic exercises (n = 51), basic exercises combined with verbal stimulation (n = 51), functional exercise training (n = 51), and functional exercise training with verbal stimulation (n = 51). No statistically significant differences in baseline characteristics were observed across the groups. Data were collected at baseline and at 12 and 24-weeks following the completion of the intervention. In the group with functional exercise training with verbal stimulation, in comparison to the group with basic exercises, the greatest positive short-term impact of intervention was demonstrated in terms of functional fitness (increased by 1.31 points; 95% confidence interval (CI) = 0.93–1.70), gait speed (improved by 0.17 m/s, 95% CI = 0.13–0.22), hand grip strength (by over 4 kg; 95% CI = 2.51–4.95), and upper-limb flexibility (by 10 cm; 95% CI = 5.82–12.65). There was also a significant increase in the level of free-time physical activity and an improvement in the quality of life, especially as expressed in the domain of overall physical functioning. Our study showed that a functional exercise program, combined with verbal stimulation, is effective at improving physical fitness and raising the level of free-time physical activity.

The Role of Muscle Mass Gain Following Protein Supplementation Plus Exercise Therapy in Older Adults with Sarcopenia and Frailty Risks: A Systematic Review and Meta-Regression Analysis of Randomized Trials

Aging and frailty are associated with a high risk of lean mass (LM) loss, which leads to physical disability and can be effectively alleviated by protein supplementation (PS) and muscle strengthening exercise (MSE). In this study, the associations between LM gain and PS + MSE efficacy (measured using physical outcomes) in elderly patients with a high risk of sarcopenia or frailty were identified. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) reporting the efficacy of PS + MSE in elderly patients with sarcopenia or frailty. The included RCTs were analyzed using meta-analysis and risk of bias assessment. We finally included 19 RCTs in this meta-analysis with a median (range/total) Physiotherapy Evidence Database score of 7/10 (5-9/10). The PS + MSE group exhibited significant improvements in the whole-body LM (standard mean difference (SMD) = 0.66; p < 0.00001), appendicular LM (SMD = 0.35; p < 0.00001), leg strength (SMD = 0.65; p < 0.00001), and walking capability (SMD = 0.33; p = 0.0006). Meta-regression analyses showed that changes in appendicular LM were significantly associated with the effect sizes of leg strength (β = 0.08; p = 0.003) and walking capability (β = 0.17; p = 0.04), respectively. Our findings suggest that LM gain after PS + MSE significantly contributes to the efficacy of the intervention in terms of muscle strength and physical mobility in elderly patients with a high risk of sarcopenia or frailty.

The Best Day of the Week: New Technology Enhancing Quality of Life in a Care Home

Older people living in residential aged care facilities tend to be physically as well as socially inactive, which leads to poorer health and reduced wellbeing. A lack of recognition of the importance of social support, limited resources, lack of training and task-oriented work routines leave little time for staff to meet the social needs of residents. Through qualitative ethnographic fieldwork, this study investigates the potential for new technologies to enhance quality of life and facilitate meaningful engagement in physical and social activities among culturally and linguistically diverse residents and staff in care facilities. A continuum from nonparticipation to full participation among residents was observed when Touch Screen Technology activities were implemented. Data indicate that resident’s engagement is impacted by five interdependent factors, including environmental, organisational, caregiver, patient, and management- &government-related. Findings show that new technologies can be used to increase meaningful physical and social engagement, including transcending language and cultural barriers. However, the successful application of new technologies to enhance quality of life is dependent on their integration into the daily routine and social relationships of staff and residents, with the full support of management. Guidelines governing the use of new technologies to support meaningful engagement of older people in residential care are lacking: this project highlights the importance of attention to the social relational dimensions of technology interventions to support best practice in their use.

Guidelines-Driven Educational Intervention Promotes Healthy Lifestyle Among Adolescents and Adults: A Serbian National Longitudinal Study

Background and objectives: The effectiveness of short-term focused educational programs to change health behaviors across large populations seems to be poorly described so far. The main aim of the present study was to evaluate an age-specific 45-min educational program, designed in accordance with the current U.S. Department of Health and Human Services and U.S. Department of Agriculture dietary guidelines and physical activity (PA) guidelines, among adolescents and adults. Materials and Methods: We evaluated the health-promoting lifestyle habits by the Health-Promoting Lifestyle Profile (HPLP-II) at baseline and following 6–8 weeks post-education in a nationally representative sample of Serbian adolescents and adults (n = 3822). Results: The percentage of adolescents eating 3–5 servings of vegetables per day increased at follow-up (20.1% versus 23.1%, p = 0.001), with significantly more adolescents regularly reading food labels (from 12.2% at baseline to 14.2% at follow-up; p = 0.02). Taken together, mean HPLP-II scores in adolescents significantly improved for both diet (0.05 points; p < 0.0001) and PA (0.09 points; p < 0.0001), and for PA in adults (0.08 points; p < 0.0001). Hierarchical multiple regression analysis revealed that our model as a whole (including time of testing as a predictor variable, and age and gender as control variables) explained 3.0% of the variance in mean HPLP-II scores for diet (p = 0.942) and 3.0% for PA (p = 0.285) in adolescents, and 1.1% of the variance in HPLP-II scores for diet (p = 0.781) and 1.9% for PA (p = 0.075) in adults, respectively. Conclusions: It appears that a brief focused education can positively tackle unhealthy lifestyles in promoting good health in general population. Different modes of interactive communication used here appeared to strengthen participants’ capacities for lifestyle changes.

Effects of Protein Supplementation Combined with Exercise Intervention on Frailty Indices, Body Composition, and Physical Function in Frail Older Adults

Aging poses a high risk of lean mass loss, which can be effectively improved through resistance exercise training (RET), or multicomponent exercise training (MET) as well as nutrition supplementation, such as protein supplementation (PS). This study investigated the effects of PS plus exercise training on frail older individuals. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) that reported the efficacy of PS combined with RET or MET in frail older individuals. The included RCTs were analyzed through a meta-analysis and risk-of-bias assessment. We finally included 22 RCTs in the meta-analysis, with a mean (range/total) Physiotherapy Evidence Database score of 6.7 (4⁻9/10). PS plus exercise training significantly improved the frailty status (odds ratio = 2.77; p = 0.006), lean mass (standard mean difference (SMD) = 0.52; p < 0.00001), leg strength (SMD = 0.37; p < 0.00001), and walking speed (SMD = 0.32; p = 0.002). Subgroup analyses revealed that PS plus MET exert significant effects on frailty indices, whereas PS plus RET further improves lean mass. Our findings suggest that PS plus RET as well as MET is effective in improving frailty status, lean mass, muscle strength, and physical mobility in frail older individuals.

Long-term evaluation of the implementation of a large fall and fracture prevention program in long-term care facilities

Background

Falls and fractures are extremely frequent in long-term care facilities (LTCFs). Therefore, a fall and fracture prevention program was started in nearly 1000 LTCFs in Bavaria/Germany between 2007 and 2010. The components of the program were exercise classes, the documentation of falls, environmental adaptations, medication reviews, the recommendation to use hip protectors and education of staff. The present study aimed to provide a comprehensive evaluation of the implementation process of the program regarding results of the implementation phase and the follow-up of 3–9 years after start of implementation.

Methods

Data from numerous sources were used, including data from published studies, statistical data, health insurance claims data and unpublished data from an online questionnaire. To incorporate different aspects, time periods and results, the RE-AIM framework was applied.

Results

The program was adopted by 942 of the 1150 eligible LTCFs and reached about 62,000 residents. During the implementation phase exercise classes and recommendation about environmental adaptations were offered in nearly all LTCFs. 13.5% of the residents participated in exercise classes. Hip protectors were available for 9.2% of all residents. In the first implementation wave, femoral fracture rate was significantly reduced by 18% in the first year. At follow-up nearly 90% of all LTCFs still offered exercise classes, which were attended by about 11% of residents. However, only 10% of the exercise classes completely fulfilled the requirements of an effective strength and balance training. Individual advice about environmental adaptations was provided in 74.3% of the LTCFs and nearly all LTCFs claimed to offer hip protectors to their residents. A long-term effect of the program on femoral fractures could not be detected.

Conclusions

The program did not affect the femoral fracture rate in the long run. Possible reasons could be a high turn-over of the staff, a reduced fidelity of training components or a shift in daily priorities among the staff.