The efficacy and safety of exercise for prevention of fall-related injuries in older people with different health conditions, and differing intervention protocols: a meta-analysis of randomized controlled trials

A Tablet-Based Technology for Objective Exercise Monitoring in Vestibular Rehabilitation: Mixed Methods Study

Background

A low-cost home exercise system called VestAid has been developed to assist participants during vestibulo-ocular reflex gaze stabilization exercises outside of clinic visits. The system includes a tablet-based app for the participant and a web-based portal for the physical therapist that provides data to make judgments about exercise accuracy and performance.

Objective

The purpose of this study was to assess the feasibility and acceptability of VestAid in a pilot study of 10 participants (mean age 45 [SD 19] years; 6 women) with various vestibular diagnoses.

Methods

All participants completed twelve 30-second horizontal vestibulo-ocular reflex exercises in a seated position (6 "easy" and 6 "hard" exercises). The exercises differed by variations in the background color, pattern, and movement. One of the exercises was repeated to assess the test-retest reliability of the measure of gaze stability accuracy and head motion compliance during the exercise. Participants rated the difficulty of the exercises (0-10 where 0=easy, 10=difficult) and completed usability surveys.

Results

Participants completed the VestAid session without adverse events. The responses from the usability survey demonstrate the acceptability of VestAid. The mean rating of the "easy" exercises was 2.7/10 (SD 1.9). The mean rating for the "difficult" exercises across participants was 4.8/10 (SD 2.1).

Conclusions

The consistency of the mean ratings of the participants with the exercise classifications ("easy" and "difficult") suggests that VestAid has clinical utility.

Sentinel fracture: the necessity of improved post-fracture care

Fragility fractures caused by osteoporosis, the most common metabolic bone disease, place a significant burden on affected individuals and impose substantial economic costs. A fragility fracture implies an imminent elevated risk for subsequent fractures, particularly in the short term. Therefore, osteoporosis must be addressed in the event of a sentinel fracture, if not already previously treated. Regardless of whether the fracture is treated conservatively or surgically, post-fracture care is particularly important. Early mobilization followed by fall risk assessment and the initiation of adequate bone-specific medication are essential milestones in preventing subsequent fractures. Monitoring patients increases adherence to bone-specific medication and fall prevention strategies. Comprehensive post-fracture care is important and should be performed by a multidisciplinary team. Coordinated care models, such as the fracture liaison service (FLS), have shown enhancements in the initiation of and adherence to secondary prevention of fragility fractures. Despite recommendations by several guidelines including that published by the Austrian Society for Bone and Mineral Research, only one fracture liaison service has been implemented in Austria.

A High Fall Risk Patient Perspective-Reducing Safety Challenges in an Acute Care Hospital

AIMS

This study examined patient perspectives of the factors that contributed to their falls in a medical ward and how patient understanding of the implemented fall prevention strategies influenced their perceptions of their fall risk.

DESIGN

An exploratory sequential mixed methods design.

METHODS

Quantitative data were obtained from the RiskMan fall database and auditing of the Patient-Centred Care Plan to identify patients who experienced a fall on the ward. From this cohort, seven inpatients were interviewed using a structured interview questionnaire to explore their perceptions of why they fell. Other complexities of fall management in the ward were discussed, including the assessment and identification of high fall risk patients and the effectiveness of patient education.

RESULTS

Five contributing factors were seen to have led to inpatient falls in the medical ward: (1) there seems to be little, if any, patient engagement with the advice in the fall prevention brochure distributed on admission; (2) insufficient patient awareness of the various fall prevention strategies; (3) inadequate bathroom supervision provided by nurses; (4) patient call bells not answered promptly, which encouraged patients engaging in risk-taking behaviour and (5) a breakdown in communication between nursing staff and patients. The study identified several factors that should be included in fall administrative data, such as the duration of call-bell response, the quality of nurse-patient communication and the determinants influencing patient response to fall prevention strategies. The study findings offer valuable insights to enhance the efficacy and implementation of fall prevention strategies to improve patient outcomes.

PATIENT CONTRIBUTION

Patients who had experienced a fall during their current hospital admission were interviewed. For each patient, the interview was a communication medium to explore the factors surrounding the occurrence of their fall and their knowledge of their fall risk.

[Osteoporosis-Definition, risk assessment, diagnosis, prevention and treatment (update 2024) : Guidelines of the Austrian Society for Bone and Mineral Research]

BACKGROUND

Austria is among the countries with the highest incidence and prevalence of osteoporotic fractures worldwide. Guidelines for the prevention and management of osteoporosis were first published in 2010 under the auspices of the then Federation of Austrian Social Security Institutions and updated in 2017. The present comprehensively updated guidelines of the Austrian Society for Bone and Mineral Research are aimed at physicians of all specialties as well as decision makers and institutions in the Austrian healthcare system. The aim of these guidelines is to strengthen and improve the quality of medical care of patients with osteoporosis and osteoporotic fractures in Austria.

METHODS

These evidence-based recommendations were compiled taking randomized controlled trials, systematic reviews and meta-analyses as well as European and international reference guidelines published before 1 June 2023 into consideration. The grading of recommendations used ("conditional" and "strong") are based on the strength of the evidence. The evidence levels used mutual conversions of SIGN (1++ to 3) to NOGG criteria (Ia to IV).

RESULTS

The guidelines include all aspects associated with osteoporosis and osteoporotic fractures, such as secondary causes, prevention, diagnosis, estimation of the 10-year fracture risk using FRAX®, determination of Austria-specific FRAX®-based intervention thresholds, drug-based and non-drug-based treatment options and treatment monitoring. Recommendations for the office-based setting and decision makers and institutions in the Austrian healthcare system consider structured care models and options for osteoporosis-specific screening.

CONCLUSION

The guidelines present comprehensive, evidence-based information and instructions for the treatment of osteoporosis. It is expected that the quality of medical care for patients with this clinical picture will be substantially improved at all levels of the Austrian healthcare system.

Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Falls are the most common cause of injury-related morbidity and mortality in older adults.

Objective

To systematically review evidence on the effectiveness and harms of fall prevention interventions in community-dwelling older adults.

Data Sources

MEDLINE, Cumulative Index for Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Clinical Trials for relevant English-language literature published between January 1, 2016, and May 8, 2023, with ongoing surveillance through March 22, 2024.

Study Selection

Randomized clinical trials of interventions to prevent falls in community-dwelling adults 65 years or older.

Data Extraction and Synthesis

Critical appraisal and data abstraction by 2 independent reviewers. Random-effects meta-analyses with Knapp-Hartung adjustment.

Main Outcomes and Measures

Falls, injurious falls, fall-related fractures, hospitalizations or emergency department visits, people with 1 or more falls, people with injurious falls, people with fall-related fractures, and harms.

Results

Eighty-three fair- to good-quality randomized clinical trials (n = 48 839) examined the effectiveness of 6 fall prevention interventions in older adults. This article focuses on the 2 most studied intervention types: multifactorial (28 studies; n = 27 784) and exercise (37 studies; n = 16 117) interventions. Multifactorial interventions were associated with a statistically significant reduction in falls (incidence rate ratio [IRR], 0.84 [95% CI, 0.74-0.95]) but not a statistically significant reduction in individual risk of 1 or more falls (relative risk [RR], 0.96 [95% CI, 0.91-1.02]), injurious falls (IRR, 0.92 [95% CI, 0.84-1.01]), fall-related fractures (IRR, 1.01 [95% CI, 0.81-1.26]), individual risk of injurious falls (RR, 0.92 [95% CI, 0.83-1.02]), or individual risk of fall-related fractures (RR, 0.86 [95% CI, 0.60-1.24]). Exercise interventions were associated with statistically significant reductions in falls (IRR, 0.85 [95% CI, 0.75-0.96]), individual risk of 1 or more falls (RR, 0.92 [95% CI, 0.87-0.98]), and injurious falls (IRR, 0.84 [95% CI, 0.74-0.95]) but not individual risk of injurious falls (RR, 0.90 [95% CI, 0.79-1.02]). Harms associated with multifactorial and exercise interventions were not well reported and were generally rare, minor musculoskeletal symptoms associated with exercise.

Conclusions and Relevance

Multifactorial and exercise interventions were associated with reduced falls in multiple good-quality trials. Exercise demonstrated the most consistent statistically significant benefit across multiple fall-related outcomes.

Validation of the Saga Fall Injury Risk Model

Background: Predicting fall injuries can mitigate the sequelae of falls and potentially utilize medical resources effectively. This study aimed to externally validate the accuracy of the Saga Fall Injury Risk Model (SFIRM), consisting of six factors including age, sex, emergency transport, medical referral letter, Bedriddenness Rank, and history of falls, assessed upon admission. Methods: This was a two-center, prospective, observational study. We included inpatients aged 20 years or older in two hospitals, an acute and a chronic care hospital, from October 2018 to September 2019. The predictive performance of the model was evaluated by calculating the area under the curve (AUC), 95% confidence interval (CI), and shrinkage coefficient of the entire study population. The minimum sample size of this study was 2,235 cases. Results: A total of 3,549 patients, with a median age of 78 years, were included in the analysis, and men accounted for 47.9% of all the patients. Among these, 35 (0.99%) had fall injuries. The performance of the SFIRM, as measured by the AUC, was 0.721 (95% CI: 0.662-0.781). The observed fall incidence closely aligned with the predicted incidence calculated using the SFIRM, with a shrinkage coefficient of 0.867. Conclusions: The external validation of the SFIRM in this two-center, prospective study showed good discrimination and calibration. This model can be easily applied upon admission and is valuable for fall injury prediction.

Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review

Importance

Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.

Observations

Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.

Conclusions and Relevance

More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.

Body composition, balance, functional capacity and falls in older women

BACKGROUND

The aim of this study was to examine the association of body composition, muscle strength, balance, and functional capacity on falls and fall injuries among community-dwelling older women.

METHODS

The study comprised of a 2-year randomized controlled trial involving 914 women with an average age of 76.5 (SD = 3.3) years at baseline. The women were assigned to exercise intervention (n = 457) and control groups (n = 457). Clinical measurements were conducted at baseline, 12 months and 24 months.

RESULTS

During the 2-year follow up, total of 546 women (59.7%) sustained a fall. The total number of falls was 1380 and out of these, 550 (40%) of falls were non-injurious and 745 (54%) were injurious. Higher femoral neck bone mineral density (BMD) was associated with a higher overall risk of falls [RR = 2.55 (95% CI = 1.70-3.84, p < 0.001)], but was a protective factor for severe fall injuries [RR = 0.03 (95% CI = 0.003-0.035, p < 0.01)]. Slower Timed Up and Go (TUG) was associated with an increased overall risk of falls [RR = 1.07 (95% CI = 1.05-1.10, p < 0.001)] and injuries requiring medical attention [RR = 1.10 (95% CI = 1.02-1.19, p = 0.02)]. Longer single leg standing time was a protective factor for falls [RR = 0.99 (95% CI = 0.99-1.00, p < 0.01)] and overall injurious falls [RR = 0.99 (95% CI = 0.99-1.00, p = 0.02)].

CONCLUSION

For postmenopausal women with higher femoral neck BMD appear to sustain more falls, but have a lower risk of severe fall injuries. Better TUG and single leg standing time predict lower risk of falls and fall injuries.

Investigating the emotional content of older adults engaging in a fall prevention exercise program integrated with dance movement therapy: a preliminary study

Fall prevention interventions for older adults have primarily focused on the physical aspects, overlooking the emotional aspects inherent in falls. This qualitative study presents a novel fall prevention intervention that integrates physical therapy exercise (PTE) based on the Otago Exercise Program with Dance Movement Therapy (DMT) to address the emotional experience during PTE. The aim of this study is to explore the emotional content expressed by older adults during balance-focused exercises and the unique emotional content expressions following the PTE + DMT intervention compared to the PTE intervention. Eleven older adults (aged 81-91 years) from a day center were randomly assigned to either the PTE + DMT group (n = 6) or the PTE group (n = 5). Interpretative phenomenological analysis of the instructors' observations and process diary identified three themes that emerged during the sessions: (1) self-image and self-worth, (2) the individual in relation to others, and (3) past memories. These themes highlight both similarities and differences between the groups. These findings provide valuable insights into the emotional experiences encountered by older adults, particularly in the context of falls prevention practices. Recognizing, understanding, and facilitating the expression of these experiences can enhance the effectiveness of fall prevention interventions and contribute to the overall health of older adults.

Exercise for prevention of falls and fall-related injuries in neurodegenerative diseases and aging-related risk conditions: a meta-analysis

Introduction

Neurodegenerative diseases often cause motor and cognitive deterioration that leads to postural instability and motor impairment, while aging-associated frailty frequently results in reduced muscle mass, balance, and mobility. These conditions increase the risk of falls and injuries in these populations. This study aimed to determine the effects of exercise on falls and consequent injuries among individuals with neurodegenerative diseases and frail aging people.

Methods

Electronic database searches were conducted in PubMed, Cochrane Library, SportDiscus, and Web of Science up to 1 January 2023. Randomized controlled trials that reported the effects of exercise on falls and fall-related injuries in neurodegenerative disease and frail aging people were eligible for inclusion. The intervention effects for falls, fractures, and injuries were evaluated by calculating the rate ratio (RaR) or risk ratio (RR) with 95% confidence interval (CI).

Results

Sixty-four studies with 13,241 participants met the inclusion criteria. Exercise is effective in reducing falls for frail aging people (RaR, 0.75; 95% CI, 0.68-0.82) and participants with ND (0.53, 0.43-0.65) [dementia (0.64, 0.51-0.82), Parkinson's disease (0.49, 0.39-0.69), and stroke survivors (0.40, 0.27-0.57)]. Exercise also reduced fall-related injuries in ND patients (RR, 0.66; 95% CI, 0.48-0.90) and decreased fractures (0.63, 0.41-0.95) and fall-related injuries (0.89, 0.84-0.95) among frail aging people. For fall prevention, balance and combined exercise protocols are both effective, and either short-, moderate-, or long-term intervention duration is beneficial. More importantly, exercise only induced a very low injury rate per participant year (0.007%; 95% CI, 0-0.016) and show relatively good compliance with exercise (74.8; 95% CI, 69.7%-79.9%).

Discussion

Exercise is effective in reducing neurodegenerative disease- and aging-associated falls and consequent injuries, suggesting that exercise is an effective and feasible strategy for the prevention of falls.

Physical Functioning in Patients with a Recent Fracture: The "Can Do, Do Do" Framework Applied to Explore Physical Capacity, Physical Activity and Fall Risk Factors

Physical capacity (PC) and physical activity (PA) are associated physical performance measures, and combined, PC and PA are used to categorize physical performance in the "can do, do do" framework. We aimed to explore physical performance of patients attending the fracture liaison service (FLS). In this cross-sectional study, PC was measured by 6-min-walking-test (can't do/can do) and PA by accelerometer (don't do/do do). Following quadrants were defined based on predefined cut-off scores for poor performance: (1) "can't do, don't do"; (2) "can do, don't do"; (3) "can't do, do do"; (4) "can do, do do". Odds ratios (OR) were calculated and fall and fracture risk factors were assessed between quadrants. Physical performance of 400 fracture patients was assessed (mean age 64; female 70.8%). Patients performed as follows: 8.3% "can't do, don't do"; 3.0% "can do, don't do"; 19.3% "can't do, do do"; 69.5% "can do, do do". For the "can't do" group the OR for low PA was 9.76 (95% CI: 4.82-19.80). Both the "can't do, don't do" and "can't do, do do" group differed significantly compared to the "can do, do do" group on several fall and fracture risk factors and had lower physical performance. The "can do, do do" framework is able to identify fracture patients with an impaired physical performance. Of all FLS patients 20% "can't do, but "do do" while having a high prevalence of fall risk factors compared to persons that "can do, do do", which may indicate this group is prone to fall.

A summary of the Malaysian Clinical Practice Guidelines on the management of postmenopausal osteoporosis, 2022

Objectives

The aim of these Clinical Practice Guidelines is to provide evidence-based recommendations to assist healthcare providers in the screening, diagnosis and management of patients with postmenopausal osteoporosis (OP).

Methods

A list of key clinical questions on the assessment, diagnosis and treatment of OP was formulated. A literature search using the PubMed, Medline, Cochrane Databases of Systematic Reviews, and OVID electronic databases identified all relevant articles on OP based on the key clinical questions, from 2014 onwards, to update from the 2015 edition. The articles were graded using the SIGN50 format. For each statement, studies with the highest level of evidence were used to frame the recommendation.

Results

This article summarizes the diagnostic and treatment pathways for postmenopausal OP. Risk stratification of patients with OP encompasses clinical risk factors, bone mineral density measurements and FRAX risk estimates. Non-pharmacological measures including adequate calcium and vitamin D, regular exercise and falls prevention are recommended. Pharmacological measures depend on patients' fracture risk status. Very high-risk individuals are recommended for treatment with an anabolic agent, if available, followed by an anti-resorptive agent. Alternatively, parenteral anti-resorptive agents can be used. High-risk individuals should be treated with anti-resorptive agents. In low-risk individuals, menopausal hormone replacement or selective estrogen receptor modulators can be used, if indicated. Patients should be assessed regularly to monitor treatment response and treatment adjusted, as appropriate.

Conclusions

The pathways for the management of postmenopausal OP in Malaysia have been updated. Incorporation of fracture risk stratification can guide appropriate treatment.

Cost-effectiveness of exercise versus multimodal interventions that include exercise to prevent falls among community-dwelling older adults: A systematic review and meta-analysis

OBJECTIVE

To compare the cost-effectiveness of exercise as a unimodal intervention versus multimodal interventions that included exercise in conjunction with other falls prevention strategies to prevent falls among community-dwelling older adults.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, NHS EED, and CINAHL (1 January 1946 to June 2022).

ELIGIBILITY CRITERIA

Economic evaluations of fall prevention strategies that included exercise delivered as a unimodal intervention or a multimodal intervention that included exercise in conjunction with other falls prevention strategies among community-dwelling adults aged 60 years and over.

RESULTS

Eighteen studies were included in this review: 9 unimodal, 6 multimodal, and 3 that included exercise delivered as both a unimodal and a multimodal intervention. In the cost-effectiveness analyses, 61.5 % (n = 8/13) of exercise-only unimodal interventions demonstrated cost-effectiveness, compared with 33.3 % (n = 2/6) of multimodal interventions. In the cost-utility analyses, 60 % (n = 6/10) of unimodal interventions compared with zero multimodal interventions (n = 0/4) demonstrated cost-effectiveness. Sixteen studies (25,017 participants) were included in our meta-analysis. Incremental costs were $128 [-$661, $1644] (2021 US dollars) for exercise-only unimodal interventions and $786 [-$72, $1644] for multimodal interventions. Estimated incremental quality-adjusted life-years was 0.09 [-0.37, 0.55] for exercise-only unimodal interventions and 0.00 [-0.04, 0.04] for multimodal interventions. Both exercise-only and multimodal interventions had an estimated 28 % reduction in falls versus the control, with incidence rate ratios for exercise-only unimodal interventions of 0.72 [0.62, 0.83] and for multimodal interventions of 0.72 [0.25, 2.09].

CONCLUSION

Exercise delivered as a unimodal intervention, particularly resistance training, provided the best value for money for fall prevention. Multimodal interventions that included exercise did not demonstrate additional benefits in terms of costs, quality of life, or fall prevention compared with exercise-only unimodal interventions. This finding may be due to the smaller number of multimodal interventions available.

REVIEW REGISTRATION

PROSPERO CRD42022295561.

REGISTRATION TITLE

Comparing the cost-effectiveness of multimodal versus unimodal interventions that include exercise to prevent falls among community-dwelling older adults: A systematic review.

Effect of a video-assisted fall prevention program on fall incidence in community-dwelling older adults during COVID

BACKGROUND

The study evaluated the effectiveness of a video-assisted exercise intervention program on fall incidence, activities of daily living, and fear of falling in community-dwelling older adults.

METHODS

A video-assisted 16-week exercise intervention consisting of stretching, strengthening, balance, and dual-task training was delivered to randomly selected 95 older adults with a high risk of falls. The fidelity of implementation was assessed for three areas; exercise program delivery, participant receipt, and enactment.

RESULTS

The fall incidence reduced significantly by 45% (IRR 0.55, (95% CI, 0.13-0.86) and difficulty in daily activities decreased (OR: 0.74, 95% CI, 0.16 - 0.96) among participants in the intervention group. Fear of falls did not show any significant difference in the groups at the 12-month follow-up.

CONCLUSION

The video-assisted exercise program was found to be effective in reducing fall incidence among older adults at a higher risk of falls.

Feasible Intervention through Simple Exercise for Risk of Falls in Dementia Patients: A Pilot Study

Physical exercise can help older people maintain capacities such as muscle strength, balance, postural control, bone mass, and functionality in ADL that usually decline with age. Dementia patients can attend day care centers where they participate in activities such as cognitive training, music and art therapy, and physical exercise sessions. This research aimed to determine the effectiveness of simple lower limb strength and single leg stance training, feasible in the facilities of day care centers, to reduce the risk of falls in the elderly with dementia. Twenty patients with dementia were divided into intervention and control groups. They participated in mobility, strength, coordination, and balance exercise sessions for 45-50 min on weekdays for 5 weeks. In addition, the intervention group patients performed simple lower limb strength (sit-to-stands) and single leg stance exercises in every session. Risk of falls was assessed with the Tinetti test and the SPPB. Comparisons of post- and pre-intervention scores for the Tinetti test and SPPB were statistically increased (0.8 ± 0.7, p = 0.03; 1.5 ± 1.3 points, p = 0.02) in intervention patients. Simple lower limb strength and single leg stance exercises feasible to be done in day care facilities are effective tools for reducing the risk of falls in the elderly with dementia.

Economic evaluation of the e-Health StandingTall balance exercise programme for fall prevention in people aged 70 years and over

BACKGROUND

globally, falls and fall-related injuries are the leading cause of injury-related morbidity and mortality in older people. In our ageing society healthcare costs are increasing, therefore programmes that reduce falls and are considered value for money are needed.

OBJECTIVE

to complete an economic evaluation of an e-Health balance exercise programme that reduced falls and injurious falls in community-dwelling older people compared to usual care from a health and community-care funder perspective.

DESIGN

a within-trial economic evaluation of an assessor-blinded randomised controlled trial with 2 years of follow-up.

SETTING

StandingTall was delivered via tablet-computer at home to older community-dwelling people in Sydney, Australia.

PARTICIPANTS

five hundred and three individuals aged 70+ years who were independent in activities of daily living, without cognitive impairment, progressive neurological disease or any other unstable or acute medical condition precluding exercise.

MAIN OUTCOME MEASURES

cost-effectiveness was measured as the incremental cost per fall and per injurious fall prevented. Cost-utility was measured as the incremental cost per quality-adjusted life year (QALY) gained.

MAIN RESULTS

the total average cost per patient for programme delivery and care resource cost was $8,321 (standard deviation [SD] 18,958) for intervention participants and $6,829 (SD 15,019) for control participants. The incremental cost per fall prevented was $4,785 and per injurious fall prevented was $6,585. The incremental cost per QALY gained was $58,039 (EQ5D-5L) and $110,698 (AQoL-6D).

CONCLUSION

this evaluation found that StandingTall has the potential to be cost-effective in specific subpopulations of older people, but not necessarily the whole older population.

TRIAL REGISTRATION

ACTRN12615000138583.

UK clinical guideline for the prevention and treatment of osteoporosis

The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management.

INTRODUCTION

The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older.

METHODS

Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.

RESULTS

Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement.

CONCLUSION

The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.

Effectiveness of Whole-Body Vibration Combined with Multicomponent Training on the Risk of Falls and Quality of Life in Elderly Women with Osteoporosis: Study Protocol for a Randomized Controlled Clinical Trial

Osteoporosis and the risk of falls increase the risk of fractures and events of falls. Prescriptions and programs for different forms of exercise have different impacts on the risk of falls, and exercises from multiple categories of whole-body vibration can be effective. This study aims to evaluate the effectiveness of whole-body vibration (WBV) protocol combined with multicomponent training (MCT) in elderly women with osteoporosis and their history of falls. Our proposal is a protocol for a randomized clinical trial, divided into two stages: First, development of a protocol for WVB combined with MCT for elderly women with osteoporosis and a history of falls, under the Guidelines of the American College of Sports Medicine, and following the recommendations of the Standard Protocol Items Recommendations for Interventional Trials (SPIRIT), and second, a randomized controlled clinical trial following the Consolidated Standards of Reporting Trials (CONSORT). This trial will have implications for the effectiveness of a vibration protocol combined with multicomponent exercise on the risk of falls and quality of life for older women with osteoporosis. We expect that adding full-body vibration to an exercise protocol will decrease the risk of falls and improve participants’ quality of life, as well as their strength, balance, and functional capacity.

The age-related decline in spatiotemporal gait characteristics is moderated by concerns of falling, history of falls & diseases, and sociodemographic-anthropometric characteristics in 60-94 years old adults

BACKGROUND

Associations between age, concerns or history of falling, and various gait parameters are evident. Limited research, however, exists on how such variables moderate the age-related decline in gait characteristics. The purpose of the present study was to investigate the moderating effects of concerns of falling (formerly referred to as fear of falling), history of falls & diseases, and sociodemographic characteristics on changes in gait characteristics with increasing age in the elderly.

METHODS

In this individual participant level data re-analysis, data from 198 participants (n = 125 females) from 60 to 94 years of age were analysed (mean 73.9, standard deviation 7.7 years). Dependent variables were major spatiotemporal gait characteristics, assessed using a capacitive force measurement platform (zebris FDM-T). Age (independent variable) and the moderating variables concerns of falling (FES-I), gender/sex, history of falls and fall-related medical records, number of drugs daily taken, and body mass index were used in the statistical analysis. Hierarchical linear mixed moderation models (multilevel analysis) with stepwise (forward) modelling were performed.

RESULTS

Decreases of gait speed (estimate = -.03, equals a decrease of 0.03 m/s per year of ageing), absolute (- 1.4) and gait speed-normalized (-.52) stride length, step width (-.08), as well as increases in speed normalized cadence (.65) and gait speed variability (.15) are all age-related (each p < .05). Overall and specific situation-related concerns of falling (estimates: -.0012 to -.07) were significant moderators. History of potentially gait- and/or falls-affecting diseases accelerated the age-related decline in gait speed (-.002) and its variability (.03). History of falls was, although non-significant, a relevant moderator (in view of increasing the model fit) for cadence (.058) and gait speed (-.0027). Sociodemographics and anthropometrics showed further moderating effects (sex moderated the ageing effect on stride length, .08; height moderated the effect on the normalised stride length, .26; BMI moderated the effects on step width, .003). .

CONCLUSION

Age-related decline in spatiotemporal gait characteristics is moderated by concerns of falling, (non-significantly) by history of falls, significantly by history of diseases, and sociodemographic characteristics in 60-94 years old adults. Knowing the interactive contributions to gait impairments could be helpful for tailoring interventions for the prevention of falls.

TRIAL REGISTRATION

Re-analysis of [21-24].

Mild Traumatic Brain Injury in Older Adults: Are Routine Second cCT Scans Necessary?

Fall-related hospitalizations among older adults have been increasing in recent decades. One of the most common reasons for this is minimal or mild traumatic brain injury (mTBI) in older individuals taking anticoagulant medication. In this study, we analyzed all inpatient stays from January 2017 to December 2019 of patients aged > 75 years with a mTBI on anticoagulant therapy who received at least two cranial computer tomography (cCT) scans. Of 1477 inpatient stays, 39 had primary cranial bleeding, and in 1438 the results of initial scans were negative for cranial bleeding. Of these 1438 cases, 6 suffered secondary bleeding from the control cCT scan. There was no significance for bleeding related to the type of anticoagulation. We conclude that geriatric patients under anticoagulant medication don’t need a second cCT scan if the primary cCT was negative for intracranial bleeding and the patient shows no clinical signs of bleeding. These patients can be dismissed but require an evaluation for need of home care or protective measures to prevent recurrent falls. The type of anticoagulant medication does not affect the risk of bleeding.

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.

Impact of different training modalities on anthropometric outcomes in patients with obesity: A systematic review and network meta-analysis

Obesity management guidelines consistently advise aerobic training for weight loss, whereas recommendations for other training modalities are sparse. This systematic review and network meta-analysis (NMA) aimed to compare the long-term effects of different training modalities on anthropometric outcomes in patients with obesity. MEDLINE, Cochrane CENTRAL, and Web of Science were searched to identify the following: (1) randomized controlled trials (RCTs); (2) conducted in adults with a mean body mass index (BMI) ≥30 kg/m² ; (3) comparing aerobic, resistance, combined, or high-intensity interval training head-to-head or to control for ≥6 months; and (4) reporting changes in body weight (BW), BMI, waist circumference (WC), fat mass (FM), or fat-free mass (FFM). Random-effects NMA models were fitted in a frequentist approach. GRADE framework was used to assess certainty of evidence. Thirty-two RCTs with 4774 participants with obesity were included in this review. Aerobic training was ranked as best for improving BW, BMI, and WC and combined training for improving FM, as well as equally with resistance training most effective for improving FFM. Low to moderate certainty of evidence supports use of aerobic training to improve anthropometric outcomes in obesity, and its combination with resistance training provides additional benefit for reducing FM and increasing FFM.

Bone-friendly lifestyle and the role of calcium or vitamin D supplementation

Bone health can be optimized by not smoking, limiting alcohol intake to ≤2 drinks/day and maintaining a healthy body weight (i.e. body mass index of about 25 kg/m²). A balanced diet with a protein content of about 1 g/kg/day and a calcium content >500 mg/day (e.g. two servings of dairy products or equivalent) is recommended. In those with poor sunlight exposure, use of a vitamin D supplement of 400-1000 IU/day should be considered. Calcium supplements cause side effects and are of unproven value. Their use is discouraged.

E-health StandingTall balance exercise for fall prevention in older people: results of a two year randomised controlled trial

OBJECTIVE

To test whether StandingTall, a home based, e-health balance exercise programme delivered through an app, could provide an effective, self-managed fall prevention programme for community dwelling older people.

DESIGN

Assessor blinded, randomised controlled trial.

SETTING

Older people living independently in the community in Sydney, Australia.

PARTICIPANTS

503 people aged 70 years and older who were independent in activities of daily living, without cognitive impairment, progressive neurological disease, or any other unstable or acute medical condition precluding exercise.

INTERVENTIONS

Participants were block randomised to an intervention group (two hours of StandingTall per week and health education; n=254) or a control group (health education; n=249) for two years.

MAIN OUTCOME MEASURES

The primary outcomes were the rate of falls (number of falls per person year) and the proportion of people who had a fall over 12 months. Secondary outcomes were the number of people who had a fall and the number who had an injurious fall (resulting in any injury or requiring medical care), adherence, mood, health related quality of life, and activity levels over 24 months; and balance and mobility outcomes over 12 months.

RESULTS

The fall rates were not statistically different in the two groups after the first 12 months (0.60 falls per year (standard deviation 1.05) in the intervention group; 0.76 (1.25) in the control group; incidence rate ratio 0.84, 95% confidence interval 0.62 to 1.13, P=0.071). Additionally, the proportion of people who fell was not statistically different at 12 months (34.6% in intervention group, 40.2% in control group; relative risk 0.90, 95% confidence interval 0.67 to 1.20, P=0.461). However, the intervention group had a 16% lower rate of falls over 24 months compared with the control group (incidence rate ratio 0.84, 95% confidence interval 0.72 to 0.98, P=0.027). Both groups had a similar proportion of people who fell over 24 months (relative risk 0.87, 95% confidence interval 0.68 to 1.10, P=0.239), but the proportion of people who had an injurious fall over 24 months was 20% lower in the intervention group compared with the control group (relative risk 0.80, 95% confidence interval 0.66 to 0.98, P=0.031). In the intervention group, 68.1% and 52.0% of participants exercised for a median of 114.0 min/week (interquartile range 53.5) after 12 months and 120.4 min/week (38.6) after 24 months, respectively. Groups remained similar in mood and activity levels. The intervention group had a 0.03 (95% confidence interval 0.01 to 0.06) improvement on the EQ-5D-5L (EuroQol five dimension five level) utility score at six months, and an improvement in standing balance of 11 s (95% confidence interval 2 to 19 s) at six months and 10 s (1 to 19 s) at 12 months. No serious training related adverse events occurred.

CONCLUSIONS

The StandingTall balance exercise programme did not significantly affect the primary outcomes of this study. However, the programme significantly reduced the rate of falls and the number of injurious falls over two years, with similar but not statistically significant effects at 12 months. E-health exercise programmes could provide promising scalable fall prevention strategies.

TRIAL REGISTRATION

ACTRN12615000138583.

Exercise training in patients after kidney transplantation

Kidney transplantation is the treatment of choice for patients with end-stage renal disease. Next to the risk of allograft failure, major obstacles for disease-free survival after kidney transplantation include a higher incidence of cancer, infection and cardiovascular events. Risk factors for adverse clinical outcomes include pre-existent comorbidities, the introduction of an immunodeficient status and (lack of) lifestyle changes after transplantation. Indeed, physical inactivity and poor physical fitness are important targets to address in order to improve clinical outcomes after kidney transplantation. This review summarizes the current evidence on exercise training after kidney transplantation, derived from randomized controlled trials. As much as possible, results are discussed in the perspective of the Standardized Outcomes in Nephrology-Transplantation core outcomes, which were recently described as critically important outcome domains for trials in kidney transplant recipients.

Exercise interventions for older adults: A systematic review of meta-analyses

BACKGROUND

The evidence concerning which physical exercise characteristics are most effective for older adults is fragmented. We aimed to characterize the extent of this diversity and inconsistency and identify future directions for research by undertaking a systematic review of meta-analyses of exercise interventions in older adults.

METHODS

We searched the Cochrane Database of Systematic Reviews, PsycInfo, MEDLINE, Embase, CINAHL, AMED, SPORTDiscus, and Web of Science for articles that met the following criteria: (1) meta-analyses that synthesized measures of improvement (e.g., effect sizes) on any outcome identified in studies of exercise interventions; (2) participants in the studies meta-analyzed were adults aged 65+ or had a mean age of 70+; (3) meta-analyses that included studies of any type of exercise, including its duration, frequency, intensity, and mode of delivery; (4) interventions that included multiple components (e.g., exercise and cognitive stimulation), with effect sizes that were computed separately for the exercise component; and (5) meta-analyses that were published in any year or language. The characteristics of the reviews, of the interventions, and of the parameters improved through exercise were reported through narrative synthesis. Identification of the interventions linked to the largest improvements was carried out by identifying the highest values for improvement recorded across the reviews. The study included 56 meta-analyses that were heterogeneous in relation to population, sample size, settings, outcomes, and intervention characteristics.

RESULTS

The largest effect sizes for improvement were found for resistance training, meditative movement interventions, and exercise-based active videogames.

CONCLUSION

The review identified important gaps in research, including a lack of studies investigating the benefits of group interventions, the characteristics of professionals delivering the interventions associated with better outcomes, and the impact of motivational strategies and of significant others (e.g., carers) on intervention delivery and outcomes.