Validation of Evidence-Based Fall Prevention Programs for Adults with Intellectual and/or Developmental Disorders: A Modified Otago Exercise Program

The effectiveness of Otago exercise program in older adults with frailty or pre-frailty: A systematic review and meta-analysis

BACKGROUND

Frailty is a well-recognized risk factor for adverse health-related outcomes in aging population. However, little is known about the dynamic changing nature of frailty and the potential for it to be modified within the scope of exercise. Currently, there has not been a systematic review of the impact of Otago exercise program (OEP) implementation specifically for the frail or pre-frail older adults.

OBJECTIVE

To determine the effectiveness of Otago exercise program on the degree of frailty, physical balance ability, mobility, grip strength and health-related quality of life in older adults with frailty or pre-frailty.

METHODS

We conducted literature searching in seven electronic databases, as well as hand-search of reference of included studies from inception to December 2022. Eligible studies included clinical trials of pre-frail or frail elderly receiving OEP interventions reporting on the relevant outcomes. The effect size was evaluated using standardized mean differences (SMDs) and its 95% confidence interval with random effects models. Risk of bias was appraised independently by two authors.

RESULTS

10 trials containing 8 RCTs and 2 non-RCTs studies were included. Five studies were evaluated with some concerns in the evidence quality. The results showed that the OEP intervention could possibly reduce the level of frailty (SMD=-1.14, 95% CI: -1.68∼-0.06, P < 0.01) and improve the mobility (SMD=-2.15, 95% CI: -3.35∼-0.94, P < 0.01) and physical balance ability (SMD=2.59, 95% CI: 1.07-4.11), P = 0.01), and enhance their grip strength (SMD=1.68, 95% CI=0.05∼3.31, P = 0.04). However, no statistically significant effect of OEP on quality of life (SMD=-1.517, 95% CI=-3.18∼0.15, P = 0.07) in frail elderly was found based on the current evidence. The subgroup analysis indicated that participant age, different intervention total duration and per min of each session have varying degrees of impact on frail or pre-frail older people.

CONCLUSIONS

The OEP intervention targeting older adults with frailty or pre-frailty are effective in reducing frailty, improving physical balance ability, mobility, and grip strength with low to moderate certainty. More rigorous and tailored research are still needed in the future to further enrich the evidence in these fields.

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.

Feasibility of a Modified Otago Exercise Program for Older Adults With Cognitive Vulnerability

Cognitive vulnerability, that is, clinically significant symptoms of dementia, depression, or delirium, puts older adults at high risk for physical inactivity and falls. Programs addressing activity and falls are needed. The purpose was to determine feasibility of an in-home, modified, Otago Exercise Program (OEP) for those with cognitive vulnerability, based on acceptability (retention and adherence), safety (pain intensity and falls), and potential positive effects (change in short physical performance battery (SPPB)). This secondary analysis of a randomized controlled trial included 80 participants who received the OEP; 64 completed it, 48% had depression, 22% had dementia, and 30% had a combination dementia/depression/delirium. Adherence to home exercise was low to moderate; pain was stable over 16 weeks; 31% of participants reported falls unrelated to OEP. SPPB increased from 6.95 to 7.74 (p < .01); age by time and diagnosis by time interactions were not significant. The modified OEP shows promising feasibility for older adults with cognitive vulnerability.

Physical Exercise Program on Fall Prevention Using Technological Interface: Pretest Study

Background

Prevention of falls among older adults has boosted the development of technological solutions, requiring testing in clinical contexts and robust studies that need prior validation of procedures and data collection tools.

Objective

The objectives of our study were to test the data collection procedure, train the team, and test the usability of the FallSensing Games app by older adults in a community setting.

Methods

This study was conducted as a pretest of a future pilot study. Older adults were recruited in a day care center, and several tests were applied. Physical exercise sessions were held using the interactive FallSensing Games app. Nurse training strategies was completed.

Results

A total of 11 older adults participated. The mean age was 75.08 (SD 3.80) years, mostly female (10/11, 91%) and with low (3-6 years) schooling (10/11, 91%). Clinically, the results show a group of older adults with comorbidities. Cognitive evaluation of the participants through the Mini Mental State Examination showed results with an average score of 25.64 (SD 3.5). Functional capacity assessed using the Lawton Instrumental Activities of Daily Living Scale (overall score from 0-23, with lower scores reflecting worse capacity to perform activities) showed impairment in different instrumental activities of daily living (average score 14.27). The data collection tool proved to enable easy interpretation; however, its structure needed small adjustments to facilitate the data collection process. Despite the length of the questionnaire, its implementation took an average of 21 minutes. For the assessment of the prevalence of fear of falling, the need to add a question was identified. The performance of functional tests under the guidance and presence of rehabilitation nurses ensured the safety of the participants. The interactive games were well accepted by the participants, and the physical exercises allowed data collection on the functionality of the older adults, such as the number of repetitions in the tests, range of movement (angle), duration of the movements, and execution of each cycle. Concerning the training of the nurses, it was crucial that they had experience with the platform, specifically the position of the chair facing the platform, the position of the feet, the posture of participants, and the use of sensors.

Conclusions

In the future pilot study, the researchers point out the need to design a study with mixed methods (quantitative and qualitative), thus enriching the study results.

Effects of a modified Otago exercise program delivered through outpatient physical therapy to community-dwelling older adult fallers in Greece during the COVID-19 pandemic: a controlled, randomized, multicenter trial

Aim

To investigate the effectiveness of a video-supported OTAGO exercise program (OEP) in balance, functional ability, fear of falls and number of falls in Greek older adults with a history of falls.

Findings

A 6-month OEP helped older adults to improve their balance and functional ability test scores as well as reduce fear and number of falls, both after the intervention and at the 12-month follow-up. However, the adherence to the program remained unaffected.

Message

The OEP contributes to the well-being of older adults with a history of falls by improving all their relevant skills and scores. More long-term research under less adverse conditions is required to solidify these findings.

Background

The pandemic has led to the isolation and social exclusion of older adults and cut them off from any exercise activity. Thus, it is more than ever necessary to implement organized interventions to prevent falls in older people as they remain a global health problem associated with serious injuries, chronic disability, and high costs for the healthcare system. Otago exercise program (OEP) can effectively reduce the number of falls.

Aim

To study the effect of a 6 months modified video supported OEP in balance, functional ability, fear of falls and number of falls in Greek older people who have fallen.

Method

150 fallers aged 65–80 years [Median age 70 (67–74), 88.7% women] were divided into two groups (intervention and control). Primary outcomes included changes in Short FES-I, CONFbal scale, 4-Stage Balance test, BBS, TUG test and number of falls, while the secondary outcome consists of the monthly adherence to exercise after the intervention. Analysis of variance with repeated measures was applied.

Results

There were statistically significant between groups differences after 6 months with the OEP group to shows improved values in TUG time score (17.8 vs 3.9%, p < 0.001, 95% CI), 4-Stage Balance Test (6.85 vs 1.09%, p < 0.05 95% CI), 30-Second Chair Stand Test 7.35 vs 2.93%, p < 0.001), BBS score (13.27 vs 3.89%, p < 0.001, 95% CI), Short FES-I (35.78 vs 13.01%, p < 0.001, 95% CI) and number of falls (69.12 vs 18.70%, p < 0.001, 95% CI). All the above differences remained statistically significant in the 12 months follow-up (p < 0.05), when differences in the CONFbal score were also observed (p < 0.001, 95% CI). No differences were found in adherence to OEP (p > 0.05).

Conclusions

A modified OEP decreases the number of falls, improves the balance and functional ability of older adults and reduces the fear of falling. However, it did not contribute to satisfactory adherence to exercise.

Trial registration number/date of registration

NCT04330053/April 1, 2020.

Feasibility of a Small Group Otago Exercise Program for Older Adults Living with Dementia

Older adults with dementia experience more frequent and injurious falls than their cognitively-intact peers; however, there are no evidence-based fall-prevention programs (EBFPP) for this population. The Otago Exercise Program (OEP) is an EBFPP for older adults that has not been well-studied in people with dementia. We sought to explore the feasibility of group delivery of OEP in an adult day health center (ADHC) for people with dementia. We collected demographic data, Functional Assessment Staging Tool (FAST), and Mini Mental State Exam (MMSE) scores for seven participants with dementia. Pre- and post-test data included: Timed-Up-and-Go (TUG), 30-Second Chair-Stand (30s-CST), Four-Stage-Balance-Test (4-SBT), and Berg Balance Scale (BBS). We implemented a supervised group OEP, 3x/week × 8 weeks. Most participants required 1:1 supervision for optimal challenge and participation. Five participants completed the program. All had moderately severe to severe dementia based upon FAST; MMSE scores ranged from mild to severe cognitive impairment. Four of five participants crossed the threshold from higher to lower fall risk in at least one outcome (TUG, 30s-CST, 4-SBT, or BBS), and four of five participants improved by >Minimal Detectible Change (MDC90) score in at least one outcome. The group delivery format of OEP required significant staff oversight for optimal participation, making the program unsustainable.

APTA Cross Sections and Academies Recommendations for COVID-19 Core Outcome Measures

The novel coronavirus (COVID-19) emerged as a major health concern within the United States in early 2020. Because this is a novel virus, little guidance exists for best practice to evaluate this population within the field of physical therapy.

A Technological-Based Platform for Risk Assessment, Detection, and Prevention of Falls Among Home-Dwelling Older Adults: Protocol for a Quasi-Experimental Study

Background

According to the United Nations, it is estimated that by 2050, the number of people aged 80 years and older will have increased by 3 times. Increased longevity is often accompanied by structural and functional changes that occur throughout an individual’s lifespan. These changes are often aggravated by chronic comorbidities, adopted behaviors or lifestyles, and environmental exposure, among other factors. Some of the related outcomes are loss of muscle strength, decreased balance control, and mobility impairments, which are strongly associated with the occurrence of falls in the elderly. Despite the continued undervaluation of the importance of knowledge on fall prevention among the elderly population by primary care health professionals, several evidence-based (single or multifaceted) fall prevention programs such as the Otago Exercise Program (OEP) have demonstrated a significant reduction in the risk of falls and fall-related injuries in the elderly within community settings. Recent studies have strived to integrate technology into physical exercise programs, which is effective for adherence and overcoming barriers to exercise, as well as improving physical functioning.

Objective

This study aims to assess the impact of the OEP on the functionality of home-dwelling elderly using a common technological platform. Particularly, the impact on muscle strength, balance, mobility, risk of falling, the perception of fear of falling, and the perception of the elderly regarding the ease of use of technology are being examined in this study.

Methods

A quasi-experimental study (before and after; single group) will be conducted with male and female participants aged 65 years or older living at home in the district of Porto. Participants will be recruited through the network COLABORAR, with a minimum of 30 participants meeting the study inclusion and exclusion criteria. All participants will sign informed consent forms. The data collection instrument consists of sociodemographic and clinical variables (self-reported), functional evaluation variables, and environmental risk variables. The data collection tool integrates primary and secondary outcome variables. The primary outcome is gait (timed-up and go test; normal step). The secondary outcome variables are lower limb strength and muscle resistance (30-second chair stand test), balance (4-stage balance test), frequency of falls, functional capacity (Lawton and Brody - Portuguese version), fear of falling (Falls Efficacy Scale International - Portuguese version), usability of the technology (System Usability Scale - Portuguese version), and environmental risk variables (home fall prevention checklist for older adults). Technological solutions, such as the FallSensing Home application and Kallisto wearable device, will be used, which will allow the detection and prevention of falls. The intervention is characterized by conducting the OEP through a common technological platform 3 times a week for 8 weeks. Throughout these weeks, the participants will be followed up in person or by telephone contact by the rehabilitation nurse. Considering the COVID-19 outbreak, all guidelines from the National Health Service will be followed. The project was funded by InnoStars, in collaboration with the Local EIT Health Regional Innovation Scheme Hub of the University of Porto.

Results

This study was approved on October 9, 2020 by the Ethics Committee of Escola Superior de Enfermagem do Porto (ESEP). The recruitment process was meant to start in October, but due to the COVID-19 pandemic, it was suspended. We expect to restart the study by the beginning of the third quarter of 2021.

Conclusions

The findings of this study protocol will contribute to the design and development of future robust studies for technological tests in a clinical context.

Trial Registration

ISRCTN 15895163; https://www.isrctn.com/ISRCTN15895163

International Registered Report Identifier (IRRID)

PRR1-10.2196/25781

Evaluation of Implementing TOM: A Group-Based Fall Prevention Programme among Community-Dwelling Older Adults in The Netherlands

There is strong evidence that effective fall prevention elements exist, but the implementation into society remains difficult. The aim of the current study is to describe and evaluate the implementation of the fall prevention programme "Thuis Onbezorgd Mobiel" (TOM). This novel approach combines effective components into a multidisciplinary group-based programme for adults aged 65 years or older with an increased risk of falling. To investigate the impact on several health-related outcomes such as subjective health, quality of life, physical functioning, and falls, we applied a quasi-experimental pre-post design including a follow-up period. A total of 164 older adults subscribed to the programme: 80 were eligible to start and 73 completed it. The impact analysis revealed a significant improvement in subjective health, physical functioning, and quality of life directly after participating in the programme. The impact on subjective health and quality of life persisted six months after the programme. Important facilitators for the implementation of the programme were social contact and clear communication. Lack of a concrete follow-up was seen as an important barrier. The results of the current research help guide further implementation of effective fall prevention interventions in practice.

The effect of the group-based Otago exercise program on frailty among nursing home older adults with cognitive impairment

This study investigated the effect of the group-based Otago exercise program (OEP) on frailty and physical function in older adults with cognitive impairment. We recruited eighteen older adults with cognitive impairment from a nursing-home to perform the OEP three times a week, for a period of three months in a nursing home. The intervention was feasible with attending an average of 21 out of 36 sessions. The frailty score decreased significantly (p<0.05). Physical function including Time Up and Go test (TUG), 30 seconds Sit-To-Stand Test (30 s-SST) and Four-Stage Balance Test was significantly positive after intervention (all p<0.001). The group-based OEP is a potentially effective strategy for reversing frailty and improving physical function among older adults with cognitive impairment.

Effects of the Otago exercise program on falls, balance, and physical performance in older nursing home residents with high fall risk: a randomized controlled trial

PURPOSE

The aim of this study was to evaluate the effects of Otago exercises on falls, balance, and physical performance in old-aged adults with high fall risk living in a nursing home.

METHODS

This randomized controlled trial included 72 individuals over 65 years of age residing in a single nursing home in Izmir, Turkey. The participants were randomized into the Otago exercise group and walking (control) group. The Otago group performed 45 min of Otago exercises 3 days/week for 12 weeks plus a walking program on 3 other days of the week. The control group did only the walking program (minimum of 30 min 3 days/week). Number of falls, Berg Balance Scale (BBS), 30-s Chair Stand Test (30 s-CST), and 6-min Walk Test (6MWT) were assessed before the intervention and at the end of the 3-month intervention. The primary outcome was number of falls.

RESULTS

The groups were well matched in terms of age (74.6 ± 5.9 vs. 75.8 ± 4.5) and sex (p > 0.05). The Otago group showed a significantly greater reduction in number of falls at the end of the intervention (p < 0.05). Of the secondary outcomes, the Otago group had greater median increases in BBS score (p < 0.05) and 30 s-CST score (p < 0.05) post-intervention compared to the walking group. There was no significant difference between the groups in terms of post-intervention change in 6MWT distance (p > 0.05).

CONCLUSION

The Otago exercise program improved balance and physical performance and reduced falls in our sample and may be effective in falls prevention interventions for old-aged nursing home residents.

Effects of a community-based exercise program on mobility, balance, cognition, sleep, activities of daily living, and quality of life in PD: a pilot study

Aim: The primary objective of the study was to evaluate the effects of a community-based exercise program for adults with Parkinson's disease (PD). Patients & methods: This one-group pretest and post-test design involved 22 participants with PD who participated in two to three exercise sessions per week for 8 weeks. Outcomes assessed for statistical significance included balance, mobility, cognition, activities of daily living, sleep and quality of life. Results: Although exercise is positively correlated with improvements in function, this short-duration study did not demonstrate this. Qualitative themes revealed an increase in self-perceived socialization, coordination and motivation to continue exercise. Conclusion: This community-based exercise study showed improvements in socialization, self-reported coordination and motivation to exercise. Further research is needed to assess community exercise interventions for PD.

Feasibility and acceptability of Otago Exercise Programme and Prevention of Falls for Adults with Intellectual Disability: a multiple case study design

Background/Aims

Many people with intellectual disability fall frequently. Understanding fall prevention intervention characteristics will assist efficacy trials to target appropriate people. An exploration of two exercise-based fall prevention interventions is reported, focusing on viability and acceptability.

Methods

A multiple case study of adults with intellectual disability completing either the group Otago Exercise Programme or the Prevention of Falls for Adults with Intellectual Disability intervention was performed. Integrated data sources were used: semi-structured interviews with participants and support workers, observations, attendance/adherence, falls, adverse events and balance measures.

Results

In total, seven adults with varying intellectual disability levels participated. Overall, three themes enabled understanding of suitability of people to each intervention: suitability of the exercises; role of the environment; and benefits to participants.

Conclusions

Educating adults with intellectual disability and their support workers of the importance of regular exercise is key to participation. Both programmes required high levels of support and prioritisation to ensure exercises occurred and were carried out safely.

Cognitive functioning, subjective memory complaints and risky behaviour predict minor home injuries in elderly

INTRODUCTION

Home accidents are one of the major causes of death, particularly in older people, young children and women.

AIMS

The first aim of this study was to explore the role of subjective memory complaints, cognitive functioning and risky behaviour as predictors of home injuries occurred in a year in a sample of healthy Italian older adults. The second aim was to investigate the role of risky behaviour as a mediator in the relationship between subjective and objective cognitive functioning and home injuries.

METHODS

One hundred thirty-three community-dwelling older people from southern Italy were administered a battery of tests to evaluate cognitive functioning, subjective memory complaints, and risky behaviour during home activities. Risky behaviour was evaluated using the Domestic Behaviour Questionnaire, created specifically for this purpose. The number of home injuries was recorded for a year throughout monthly telephone interviews. A path analysis was performed to test the following model: cognitive functioning and subjective memory complaints directly influence risky behaviour and number of accidents over a year; risky behaviour mediates the impact of cognitive functioning and subjective memory on number of accidents over a year.

RESULTS

Path analysis confirmed the model tested except the role of risky behaviour as a mediator between cognitive functioning and home accidents.

DISCUSSION

Risky behaviour could represent a further risk factor in cognitively intact older adults with subjective memory complaints.

CONCLUSIONS

The assessment of both cognition and behaviour in elderly can make a valuable contribution in preventing home accidents in elderly.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

Instrumental or Physical-Exercise Rehabilitation of Balance Improves Both Balance and Gait in Parkinson's Disease

We hypothesised that rehabilitation specifically addressing balance in Parkinson's disease patients might improve not only balance but locomotion as well. Two balance-training protocols (standing on a moving platform and traditional balance exercises) were assessed by assigning patients to two groups (Platform, n = 15, and Exercises, n = 17). The platform moved periodically in the anteroposterior, laterolateral, and oblique direction, with and without vision in different trials. Balance exercises were based on the Otago Exercise Program. Both platform and exercise sessions were administered from easy to difficult. Outcome measures were (a) balancing behaviour, assessed by both Index of Stability (IS) on platform and Mini-BESTest, and (b) gait, assessed by both baropodometry and Timed Up and Go (TUG) test. Falls Efficacy Scale-International (FES-I) and Parkinson's Disease Questionnaire (PDQ-8) were administered. Both groups exhibited better balance control, as assessed both by IS and by Mini-BESTest. Gait speed at baropodometry also improved in both groups, while TUG was less sensitive to improvement. Scores of FES-I and PDQ-8 showed a marginal improvement. A four-week treatment featuring no gait training but focused on challenging balance tasks produces considerable gait enhancement in mildly to moderately affected patients. Walking problems in PD depend on postural instability and are successfully relieved by appropriate balance rehabilitation. This trial is registered with ClinicalTrials.gov NCT03314597.