Effect of nutritional and physical exercise intervention on hospital readmission for patients aged 65 or older: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Unplanned readmission may result in consequences for both the individual and society. The transition of patients from hospital to postdischarge settings often represents a discontinuity of care and is considered crucial in the prevention of avoidable readmissions. In older patients, physical decline and malnutrition are considered risk factors for readmission. The purpose of the study was to determine the effects of nutritional and physical exercise interventions alone or in combination after hospital admission on the risk of hospital readmission among older people. METHODS: A systematic review and meta-analysis of randomized controlled studies was conducted. The search involved seven databases (Medline, AMED, the Cochrane Library, CINAHL, Embase (Ovid), Food Science Source and Web of Science) and was conducted in November 2018. An update of this search was performed in March 2020. Studies involving older adults (65 years and above) investigating the effect of nutritional and/or physical exercise interventions on hospital readmission were included. RESULTS: A total of 11 randomized controlled studies (five nutritional, five physical exercise and one combined intervention) were included and assessed for quality using the updated Cochrane Risk of Bias Tool. Nutritional interventions resulted in a significant reduction in readmissions (RR 0.84; 95% CI 0.70-1.00, p = 0.049), while physical exercise interventions did not reduce readmissions (RR 1.05; 95% CI 0.84-1.31, p-value = 0.662). CONCLUSIONS: This meta-analysis suggests that nutrition support aiming to optimize energy intake according to patients' needs may reduce the risk of being readmitted to the hospital for people aged 65 years or older.

Health-related quality of life in home care recipients after a falls prevention intervention: a 6-month follow-up.

BACKGROUND: Falls in older adults are an increasingly important public health concern due to the expanding older population and contribute considerably to the global burden of disease. Home care recipients have a high incidence of falls and a low level of health-related quality of life (HRQOL). In this understudied group of older adults, exercise interventions could prevent falls, promote HRQOL and enable healthy ageing in the longer term. METHODS: The study is a single-blinded parallel-group randomized controlled trial, lasting 3 months with a follow-up at 6 months, conducted in primary care. The objective was to explore the effects of a falls prevention exercise programme post-intervention at a 6-month follow-up in home care recipients 67+ years with a history of falls. The Otago Exercise Programme lasting 3 months was performed. The primary outcome was HRQOL measured by the Short Form 36 Health Survey (SF-36). Linear mixed regression models and structural equation models were employed. RESULTS: At 6-month follow-up, the intervention group scored significantly higher on SF-36's physical component summary compared with the controls; 3.0 points, 95% confidence interval (CI) = 0.4, 5.6. This effect was mediated by an increased probability of maintaining exercise in the post-intervention period; odds ratio = 2.3 (CI = 1.1, 5.1). Exercising was associated with a 7.1-point increase in physical component summary (CI = 3.2, 10.9). CONCLUSION: A falls prevention exercise programme can improve physical HRQOL in home care recipients post-intervention. The exercise programme also led to longer-term changes in exercise behaviour mediating this effect.

The tensions between micro-, meso- and macro-levels: physiotherapists' views of their role towards fall prevention in the community - a qualitative study.

BACKGROUND: Falls are a global public health concern. Physiotherapists are a key resource in this context, but there is sparse knowledge about how they perceive their role in the primary care setting. Therefore, the purpose of the present study is to explore physical therapists' (PTs) view of how they experience and perceive their role working with fall prevention in a community care setting. METHODS: Semi-structured interviews were conducted with 17 physiotherapists. Data were analysed using a qualitative thematic analysis. RESULTS: The analysis resulted in a core theme and three subthemes. The core theme was 'capability to cope with the tensions between the micro-, meso- and macro-levels in fall, prevention', which indicated the importance of an evolving multifaceted, evidence based and innovative physiotherapy role. A key factor for this role is to take an integrative biopsychosocial approach based on how biological and psychosocial factors are uniquely related in fall prevention. The three themes were as follows: 1) always moving and changing: the competent explorative knowledge-hungry clinician's multifaceted role; 2) multiprofessional - but in the end alone; 3) reaching out - from the bottom to the top. Success in the role of physiotherapists in fall prevention depends on the empowering leadership and working culture, as well as on the time and multifaceted professional competence of the clinicians. CONCLUSION: Our findings indicate that the PTs' role reflects their abilities to change and improve their professional work in accordance with evidence based knowledge. To ensure good quality the PTs focused on the special needs of the patients, evidence-based fall prevention, interdisciplinary team work, good clinical competences, good skills in communication, and interpersonal relations. Attention should be placed on the importance of biopsychosocial perspective framing in the actual clinical and political context. The PTs saw the need for working at the micro-, meso- and macro-levels to succeed in the work of fall prevention.

Effects of a falls prevention exercise programme on health-related quality of life in older home care recipients: a randomised controlled trial.

BACKGROUND: falls have serious consequences for quality of life (QOL) and contribute substantially to the global burden of disease. Home care is an important arena to address falls prevention and QOL, but this vulnerable group of older adults is underrepresented in health research. This study explores the effects of a falls prevention exercise programme on health-related quality of life (HRQOL), physical function and falls self-efficacy in older fallers receiving home care. METHODS: the study design is a parallel-group randomised controlled trial. The intervention group performed a falls prevention programme based on the Otago Exercise Programme (OEP). The control group received usual care. 155 participants were recruited from primary health care in six Norwegian municipalities. Local physiotherapists supervised the programme. The primary outcome, HRQOL, was measured by the Short-Form 36 Health Survey (SF-36). Secondary outcomes were Berg Balance Scale (BBS), 30-s sit to stand (STS), 4-m walk test, instrumental activities of daily living and Falls Efficacy Scale International. RESULTS: intention-to-treat analysis showed that, compared to the control group, the intervention group improved on SF-36's physical component summary as well as BBS. However, the intervention group also demonstrated a decline in the mental health subscale of SF-36. Per-protocol analyses showed significant improvements in all physical subscales of SF-36, STS and BBS scores in the intervention group compared with the control group. CONCLUSION: a falls prevention exercise programme based on OEP significantly improved physical HRQOL and balance in older adults receiving home care. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02374307. First registration, 16 February 2015.

Evaluating a falls prevention intervention in older home care recipients: a comparison of SF-6D and EQ-5D.

PURPOSE: Health-related quality of life (HRQOL) is an important outcome in economic evaluations of health care interventions for older adults. The aim of this study was to compare two commonly used preference-based utility measures, SF-6D and EQ-5D, to provide knowledge on their applicability when evaluating falls prevention interventions in primary health care. METHODS: The study is a secondary analysis of longitudinal data from a randomised controlled trial, which included 155 older home care recipients participating in a falls prevention intervention in Norway. HRQOL was measured by SF-6D and EQ-5D. Physical function was measured by Berg Balance Scale, 4-m walk test, 30-s sit-to-stand and Falls Efficacy Scale International. Assessments were performed at baseline, 3 months and 6 months. The agreement between SF-6D and EQ-5D was examined using Bland-Altman plots and Spearman correlations. Elasticities from regression analysis were employed to compare the instruments' responsiveness. RESULTS: SF-6D and EQ-5D were strongly correlated (0.71), but there were differences in the instruments' agreement and domains of HRQOL covered. Participants with a higher mean HRQOL and/or better physical function scored generally higher on EQ-5D. Participants with a lower mean HRQOL and/or poorer physical function achieved a relatively higher score on SF-6D. EQ-5D was more responsive to changes in physical function compared to SF-6D. CONCLUSIONS: SF-6D and EQ-5D have both similarities and differences regarding sensitivity, domains covered and responsiveness to changes when evaluating a falls prevention intervention. Selecting the appropriate instrument depends on the characteristics of the participants and the intervention being evaluated.

Associations between health-related quality of life, physical function and fear of falling in older fallers receiving home care.

BACKGROUND: Falls and injuries in older adults have significant consequences and costs, both personal and to society. Although having a high incidence of falls, high prevalence of fear of falling and a lower quality of life, older adults receiving home care are underrepresented in research on older fallers. The objective of this study is to determine the associations between health-related quality of life (HRQOL), fear of falling and physical function in older fallers receiving home care. METHODS: This study employed cross-sectional data from baseline measurements of a randomised controlled trial. 155 participants, aged 67+, with at least one fall in the previous year, from six Norwegian municipalities were included. Data on HRQOL (SF-36), physical function and fear of falling (FES-I) were collected in addition to demographical and other relevant background information. A multivariate regression model was  applied. RESULTS: A higher score on FES-I, denoting increased fear of falling, was significantly associated with a lower score on almost all subscales of SF-36, denoting reduced HRQOL. Higher age was significantly associated with higher scores on physical function, general health, mental health and the mental component summary. This analysis adjusted for sex, education, living alone, being at risk of or malnourished, physical function like balance and walking speed, cognition and number of falls. CONCLUSION: Fear of falling is important for HRQOL in older fallers receiving home care. This association is independent of physical measures. Better physical function is significantly associated with higher physical HRQOL. Future research should address interventions that reduce fear of falling and increase HRQOL in this vulnerable population. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02374307 . First registration, 16 February 2015. First enrolment of participants, February 2016.

A falls prevention programme to improve quality of life, physical function and falls efficacy in older people receiving home help services: study protocol for a randomised controlled trial.

BACKGROUND: Falls and fall-related injuries in older adults are associated with great burdens, both for the individuals, the health care system and the society. Previous research has shown evidence for the efficiency of exercise as falls prevention. An understudied group are older adults receiving home help services, and the effect of a falls prevention programme on health-related quality of life is unclear. The primary aim of this randomised controlled trial is to examine the effect of a falls prevention programme on quality of life, physical function and falls efficacy in older adults receiving home help services. A secondary aim is to explore the mediating factors between falls prevention and health-related quality of life. METHODS: The study is a single-blinded randomised controlled trial. Participants are older adults, aged 67 or older, receiving home help services, who are able to walk with or without walking aids, who have experienced at least one fall during the last 12 months and who have a Mini Mental State Examination of 23 or above. The intervention group receives a programme, based on the Otago Exercise Programme, lasting 12 weeks including home visits and motivational telephone calls. The control group receives usual care. The primary outcome is health-related quality of life (SF-36). Secondary outcomes are leg strength, balance, walking speed, walking habits, activities of daily living, nutritional status and falls efficacy. All measurements are performed at baseline, following intervention at 3 months and at 6 months' follow-up. Sample size, based on the primary outcome, is set to 150 participants randomised into the two arms, including an estimated 15-20% drop out. Participants are recruited from six municipalities in Norway. DISCUSSION: This trial will generate new knowledge on the effects of an exercise falls prevention programme among older fallers receiving home help services. This knowledge will be useful for clinicians, for health managers in the primary health care service and for policy makers. TRIAL REGISTRATION: ClinicalTrials.gov . NCT02374307 . First registration, 16/02/2015.

Managers' perspectives on their role in implementing fall prevention interventions: a qualitative interview study in Norwegian homecare services.

Introduction: The implementation of fall prevention interventions in homecare services is crucial for reducing falls among older adults and effective leadership could determine success. Norwegian homecare services provide home nursing, rehabilitation, and practical assistance, to residents living in private homes or assisted living facilities. This study aims to explore how managers in Norwegian homecare services experience implementation of fall prevention interventions and how they perceive their roles. Methods: We conducted 14 semi-structured individual interviews with managers from different levels of homecare services in five city districts. The interviews were transcribed verbatim and reflexive thematic analysis was used to analyze the material. Results: The analysis resulted in three main themes: (1) understanding organizational mechanisms to facilitate new practices, (2) practicing positive leadership behavior to facilitate implementation, and (3) demonstrating persistence to sustain implementation. Our results showed the importance of clear leadership across all levels of the organization and the value of devoting time and utilizing existing systems. Managers described using recognition and positive attitudes to motivate employees in the implementation process. They emphasized listening to and involving employees, providing trust, and being flexible. However, the implementation process could be challenging, highlighting the need for managers to be persistent. Conclusion: Managers at all levels play an important role in the implementation of fall prevention, but there is a need to define and align their specific roles in the process. Understanding how to use existing systems and influence through positive leadership behavior seem to be vital for success. Recognizing the demanding nature of implementation, managers emphasized the importance of systems for long term support. The study findings may influence how managers in clinical practice engage in the implementation process and inform future researchers about managers' roles in implementation in homecare services.

Feasibility of an implementation strategy for preventing falls in homecare services.

BACKGROUND: Falls among older adults represent a major health hazard across the world. In 2022, the World Falls Guidelines was published, summarising research evidence and expert recommendations on how to prevent falls, but we need more knowledge on how the evidence can be successfully implemented into routine practice. In this study we used an implementation strategy co-created by healthcare providers, older adults who had fallen and researchers, to facilitate uptake of fall prevention recommendations. This current study aimed to evaluate the feasibility of this co-created implementation strategy in homecare services and provide information on the intervention and measurements for a full-scale cluster-randomized trial. METHODS: This study was a single-armed feasibility study with an embedded mixed-method approach completed in two city districts of Oslo, Norway, over a period of ten weeks. The co-created implementation strategy consists of a package for implementing national recommendations for preventing falls, empowering leaders to facilitate implementation, establish implementation teams, competence improvement and implementation support. City districts established implementation teams who were responsible for the implementation. Feasibility was assessed both qualitatively and quantitatively, using focus group interviews with implementation team members and individual interviews with leaders and staff members and the Feasibility of Intervention Measure (FIM). Qualitative data were analysed using thematic analysis and the Normalisation Process Theory. RESULTS: Qualitative data were collected from 19 participants: 12 implementation team members, 2 leaders and 5 staff members. 8 of the implementation team members responded to FIM. The analysis revealed four themes: 1) Fostering consensus through tailored implementation and discussions on fall prevention, 2) The importance of multi-level and interdisciplinary collaboration in fall prevention implementation, 3) Minimizing perceived time usage through utilization of existing areas for implementation activities, and 4) Reflective monitoring demonstrates the importance of facilitation and structure in the implementation strategy. For FIM, there were a high level of agreement related to how implementable, possible, doable, and easy to use the implementation strategy was. CONCLUSIONS: Overall, we found the implementation strategy to be feasible to enhance uptake of fall prevention recommendations in the Norwegian homecare services. To succeed with the implementation, a dedicated implementation team should receive support through the implementation process, they should choose small implementation activities to enhance fall prevention competence and managers should possess implementation knowledge. TRIAL REGISTRATION: The trial is registered in the Open Science Registry: https://doi.org/10.17605/OSF.IO/2JFHV Registered: January 11, 2023.

Tailored implementation of national recommendations on fall prevention among older adults in municipalities in Norway (FALLPREVENT trial): a study protocol for a cluster-randomised trial.

BACKGROUND: Despite substantial research evidence indicating the effectiveness of a range of interventions to prevent falls, uptake into routine clinical practice has been limited by several implementation challenges. The complexity of fall prevention in municipality health care underlines the importance of flexible implementation strategies tailored both to general determinants of fall prevention and to local contexts. This cluster-randomised trial (RCT) investigates the effectiveness of a tailored intervention to implement national recommendations on fall prevention among older home-dwelling adults compared to usual practice on adherence to the recommendations in health professionals. METHODS: Twenty-five municipalities from four regions in Norway will be randomised to intervention or control arms. Each municipality cluster will recruit up to 30 health professionals to participate in the study as responders. The tailored implementation intervention comprises four components: (1) identifying local structures for implementation, (2) establishing a resource team from different professions and levels, (3) promoting knowledge on implementation and fall prevention and (4) supporting the implementation process. Each of these components includes several implementation activities. The Consolidated Framework for Implementation Research (CFIR) will be used to categorise determinants of the implementation process and the Expert Recommendations for Implementing Change (ERIC) will guide the matching of barriers to implementation strategies. The primary outcome measure for the study will be health professionals' adherence to the national recommendations on fall prevention measured by a questionnaire. Secondary outcomes include injurious falls, the feasibility of the intervention, the experiences of the implementation process and intervention costs. Measurements will be carried out at baseline in August 2023, post-intervention in May 2024 and at a follow-up in November 2024. DISCUSSION: This study will provide evidence on the effectiveness, intervention costs and underlying processes of change of tailored implementation of evidence-based fall prevention recommendations. TRIAL REGISTRATION: The trial is registered in the Open Science Registry: https://doi.org/10.17605/OSF.IO/JQ9T5 . Registered: March 03, 2023.

A qualitative study exploring physical therapists' views on the Otago Exercise Programme for fall prevention: a stepping stone to "age in place" and to give faith in the future.

Background: One of the most effective interventions to prevent falls is exercise. A commonly used program that prevents falls is the Otago Exercise Programme (OEP). Despite this, user-based knowledge of its applicability in real-world settings for older adults who are dependent on formal care in their homes is lacking. Purposes: To explore how physical therapists (PTs) experience the applicability of the OEP in clinical practice for home-dwelling older adults who are dependent on formal home care and to determine their beliefs regarding the benefits of the OEP for living longer at home. Methods: Semi-structured interviews were conducted with 17 physical therapists. Data were analyzed using qualitative thematic analysis. Results: The OEP was described by PTs to be applicable in clinical practice. Their experience was that the OEP seemed to be meaningful and to have a strong relationship with everyday activities. The OEP improved physical function, mood, self-efficacy, and participation in social activities in older adults, as well as provided faith in the future. Conclusion: The OEP is suitable for use in a primary care setting, and according to the perceptions of physical therapists, the OEP contributes to older adults' capability to live longer at home.

Effectiveness of work-related interventions for return to work in people on sick leave: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Long-term sick leave is a serious concern in developed countries and the cost of sickness absence and disability benefits cause major challenges for both the individual and society as a whole. Despite an increasing body of research reported by existing systematic reviews, there is uncertainty regarding the effect on return to work of workrelated interventions for workers with different diagnoses. The objective of this systematic review was to assess and summarize available research about the effects of work-related interventions for people on long-term sick leave and those at risk of long-term sick leave. METHODS: We conducted a systematic review in accordance with international guidelines. Campbell Collaboration (Area: Social Welfare), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, Epistemonikos, MEDLINE, PsycINFO, Scopus, and Sociological Abstracts were systematically searched in March 2021. Two authors independently screened the studies. We conducted risk of bias assessments and meta-analyses of the available evidence in randomized controlled trials (RCTs). The remaining comparisons were synthesized narratively. The certainty of evidence for each outcome was assessed. RESULTS: We included 20 RCTs comprising 5753 participants at baseline from 4 different countries. The studies had generally low risk of bias. Our certainty in the effect estimates ranged from very low to moderate. Eight different interventions were identified. Meta-analysis revealed no statistically significant difference between multidisciplinary rehabilitation (MR) and usual care (US) (Risk Ratio [RR] 1.01; Confidence Interval [CI] 95% 0.70-1.48 at 12 months follow-up) and between MR and other active intervention (Risk Ratio [RR] 1.04; Confidence Interval [CI] 95% 0.86-1.25 at 12 months follow-up). Remaining intervention groups revealed marginal, or no effect compared to the control group. The results for the secondary outcomes (self-efficacy, symptom reduction, function, cost-effectiveness) showed varied and small effects in the intervention groups. CONCLUSION: Overall, the present data showed no conclusive evidence of which work-related intervention is most effective for return to work. However, a handful of potential interventions exist, that may contribute to a foundation for future research. Our findings support the need for adequately powered and methodologically strong studies.

The Effects of High-Intensity Aerobic Exercise on Cognitive Performance After Stroke: A Pilot Randomised Controlled Trial.

BACKGROUND: Aerobic exercise is an effective treatment to improve aerobic capacity following stroke and might also improve cognitive impairments in sub-acute stroke survivors. The aim of the study was to assess the effect of high-intensity aerobic exercise on cognitive impairments in sub-acute stroke survivors. METHODS: A pilot, randomised controlled trial on the effects of aerobic exercise on cognitive impairments of stroke patients in the sub-acute (1-3 months) phase was conducted. Thirty patients with moderate cognitive impairments (maximum score of 5 on at least two items on the cognitive subscales of the Functional Independence Measure [FIM]) were included in the study and randomly assigned to either the intervention group - performing high-intensity aerobic exercise (above 70% of maximum heart rate), or the control group - performing low-intensity aerobic exercise (below 60%). Patients in both groups exercised for 50 min twice a week for 4 weeks. Primary neuropsychological outcome: Trail Making Test B. RESULTS: Thirty stroke patients completed the interventions. The results showed that the high-intensity group, compared with the low-intensity group, achieved significant improvements on Trail Making Test B, which assesses processing speed and divided attention (P = .04 after training and P = .01 at follow-up). However, the significant improvements on Trail Making Test B might relate to a ceiling effect in the control group. CONCLUSIONS: This study does not provide evidence to support that aerobic exercise can improve cognition in stroke survivors, even though significant improvement was revealed on the primary outcome in sub-acute stroke survivors following high-intensity aerobic exercise compared with low-intensity general exercise.