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

BACKGROUND: Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour. OBJECTIVES: To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies. SELECTION CRITERIA: This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition. DATA COLLECTION AND ANALYSIS: Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions. AUTHORS' CONCLUSIONS: CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

Assessing life-space mobility : A systematic review of questionnaires and their psychometric properties.

BACKGROUND: Life-space mobility (LSM), as the extent of mobility within one's environment, is a key for successful aging and has become a relevant concept in gerontology and geriatric research. Adequate assessment instruments are needed to identify older persons with LSM restrictions, and to initiate, adapt or evaluate intervention strategies. OBJECTIVE: To systematically identify, describe and analyze the psychometric properties of LSM questionnaires, with a special focus on their availability in the German language. METHODS: A systematic literature search was conducted in PubMed, PsycINFO, Cochrane Library, CINAHL, and Web of Science. Studies that examined at least one psychometric property of LSM questionnaires published up to August 2021 were included and evaluated based on the consensus-based standards for the selection of health measurement instruments (COSMIN) guidelines. RESULTS: This study included 37 validation studies describing 13 different LSM questionnaires. Methodological quality and comprehensiveness of validations were heterogeneous. Based on comprehensive and high-quality results, four LSM questionnaires stood out: the University of Alabama at Birmingham life-space assessment (UAB-LSA), life-space assessment in persons with cognitive impairment (LSA-CI), interview-based and proxy-based versions of the life-space assessment in institutionalized settings (LSA-IS), all of them available in the German language. CONCLUSION: This systematic review provides a concise overview of available LSM questionnaires and their psychometric properties to facilitate the selection for use in clinical practice and research. The UAB-LSA and LSA-CI for community settings and the interview-based or proxy-based LSA-IS for institutional settings were found to be the most appropriate LSM questionnaires.

Cost-Effectiveness and Cost-Utility of a Home-Based Exercise Program in Geriatric Patients with Cognitive Impairment.

INTRODUCTION: There is a substantial lack of home-based exercise programs in the highly vulnerable group of geriatric patients with cognitive impairment (CI) after discharge from ward rehabilitation. Beyond clinical effectiveness, the cost-effectiveness of intervention programs to enhance physical performance is not well investigated in this target group. OBJECTIVE: The aim of the study was to determine the cost-effectiveness of a 12-week home-based exercise intervention following discharge from ward rehabilitation compared to unspecified flexibility training for geriatric patients with CI from a societal perspective. METHODS: This cost-effectiveness study was conducted alongside a randomized placebo-controlled trial. A total of 118 geriatric patients with CI (Mini-Mental State Examination score: 17-26) were randomized either to the intervention group (IG, n = 63) or control group (CG, n = 55). Participants in the IG received a home-based individually tailored exercise program to increase physical performance, while participants in the CG received unspecific flexibility training (placebo control). Healthcare service use, physical performance (Short Physical Performance Battery, SPPB), and quality of life (EQ-5D-3L) were measured over 24 weeks. The net monetary benefit (NMB) approach was applied to calculate incremental cost-effectiveness of the exercise intervention compared to the CG with respect to improvement of (a) physical performance on the SPPB and (b) quality-adjusted life years (QALYs). RESULTS: Physical performance was significantly improved in the IG compared to the CG (mean difference at 24 weeks: 1.3 points; 95% confidence interval [95% CI] = 0.5-2.2; p = 0.003), while health-related quality of life did not significantly differ between the groups at 24 weeks (mean difference: 0.08; 95% CI = -0.05 to 0.21; p = 0.218). Mean costs to implement the home-based exercise intervention were EUR 284 per patient. The probability of a positive incremental NMB of the intervention reached a maximum of 92% at a willingness to pay (WTP) of EUR 500 per point on the SPPB. The probability of cost-utility referring to QALYs was 85% at a WTP of EUR 5,000 per QALY. CONCLUSION: The home-based exercise intervention demonstrated high probability of cost-effectiveness in terms of improved physical performance in older adults with CI following discharge from ward rehabilitation, but not in terms of quality of life.

Validation of the interview-based life-space assessment in institutionalized settings (LSA-IS) for older persons with and without cognitive impairment.

BACKGROUND: Self-reported life-space assessment methods so far focus on community-dwelling persons, with a lack of validated assessment methods for institutionalized settings. This study evaluated construct validity, test-retest reliability, sensitivity to change, and feasibility of a new Life-Space Assessment for Institutionalized Settings (LSA-IS) in geriatric patients. METHODS: Psychometric properties of the LSA-IS in 119 hospitalized geriatric patients (83.0 ± 6.2 years) with and without cognitive impairment (CI) [Mini-Mental State Examination: 22.4 ± 4.9 scores] were evaluated within a comprehensive validation design. For the total group and subgroups according to cognitive status, construct validity was assessed by calculating Spearman's rank correlation coefficients (rho) with established construct variables, test-retest reliability by intra-class correlation coefficients (ICCs), sensitivity to change by standardized response means (SRMs) calculated for effects of early ward-based rehabilitation during hospital stay. RESULTS: The LSA-IS (total score) demonstrated good test-retest reliability (ICC = .704), and large sensitivity to change (SRM = .806), while construct validity was small to high indicated by significant correlations of the LSA-IS to construct variables (rho = .208-716), depending on relative construct association. On average results of LSA-IS sub-scores confirmed results of the total score. Subgroups according to cognitive status did not differ for most analyzed variables. A completion rate of 100% and a completion time of 3.2 ± 1.2 min documented excellent feasibility. CONCLUSIONS: The interview-based LSA-IS has proven to be valid, reliable, sensitive, and feasible in hospitalized, multi-morbid, geriatric patients with and without CI documenting good psychometric properties for institutionalized settings. TRIAL REGISTRATION: DRKS00016028.

Will We Do If We Can? Habitual Qualitative and Quantitative Physical Activity in Multi-Morbid, Older Persons with Cognitive Impairment.

This study aimed to identify determinants of quantitative dimensions of physical activity (PA; duration, frequency, and intensity) in community-dwelling, multi-morbid, older persons with cognitive impairment (CI). In addition, qualitative and quantitative aspects of habitual PA have been described. Quantitative PA and qualitative gait characteristics while walking straight and while walking turns were documented by a validated, sensor-based activity monitor. Univariate and multiple linear regression analyses were performed to delineate associations of quantitative PA dimensions with qualitative characteristics of gait performance and further potential influencing factors (motor capacity measures, demographic, and health-related parameters). In 94 multi-morbid, older adults (82.3 ± 5.9 years) with CI (Mini-Mental State Examination score: 23.3 ± 2.4), analyses of quantitative and qualitative PA documented highly inactive behavior (89.6% inactivity) and a high incidence of gait deficits, respectively. The multiple regression models (adjusted R2 = 0.395-0.679, all p < 0.001) identified specific qualitative gait characteristics as independent determinants for all quantitative PA dimensions, whereas motor capacity was an independent determinant only for the PA dimension duration. Demographic and health-related parameters were not identified as independent determinants. High associations between innovative, qualitative, and established, quantitative PA performances may suggest gait quality as a potential target to increase quantity of PA in multi-morbid, older persons.

Cut-off for the Life-Space Assessment in persons with cognitive impairment.

BACKGROUND: A version of the Life-Space Assessment in persons with cognitive impairment (LSA-CI) has recently been developed. AIMS: To establish a cut-off value for the newly developed Life-Space Assessment in persons with cognitive impairment (LSA-CI). METHODS: In a cross-sectional study including 118 multimorbid, older persons with cognitive impairment, life-space mobility (LSM) was documented by the LSA-CI. The analysis was rationalized by Global Positioning System (GPS)-based measures of spatial distance from home. A receiver-operating characteristic (ROC) curve was created and the cut-off point for the LSA-CI was identified with the Youden's Index. RESULTS: ROC curve analysis indicated a critical value of 26.75 (within a range of 0-90) to differentiate between low and high LSM with a sensitivity of 78.1% and specificity of 84.2%. DISCUSSION: Diagnostic interpretation of the ROC curves revealed that low and high LSM groups can be differentiated with the proposed cut-off. CONCLUSIONS: The proposed LSA-CI cut-off score can be recommended to tailor clinical interventions and evaluate change over time.

Effects of Standardized Home Training in Patients with Cognitive Impairment following Geriatric Rehabilitation: A Randomized Controlled Pilot Study.

BACKGROUND: Post-ward geriatric rehabilitation programs have hardly been developed and validated, which leaves a substantial gap in rehabilitative care in older adults and hinders full exploitation of maintained, but often unrecognized rehabilitation potentials. Geriatric rehabilitation patients with cognitive impairment represent a highly vulnerable population which is often affected by a lack of an ongoing support at the intersection between ward-based and post-ward rehabilitation. OBJECTIVE: To determine the effect of a standardized home-based training program in geriatric patients with cognitive impairment following ward-based rehabilitation. METHODS: A randomized controlled, single-blinded intervention trial (RCT) with wait list control design was used. Geriatric patients (n = 34; age: 81.9 ± 5.7 years) with cognitive impairment (MMSE: 18.8 ± 4.7), identified by predefined in- and exclusion criteria, were consecutively recruited from a geriatric rehab ward. Patients in the intervention group (IG, n = 17) performed a 6-week strength and functional home training. The control group (CG, n = 17) started an identical training 6 weeks later with an initial usual care period during the intervention for the IG. Functional performance (Short Physical Performance Battery; SPPB), clinically relevant functional deficits (Performance Oriented Assessment; POMA), and physical activity (Assessment of Physical Activity For Older Persons questionnaire; APAFOP) represented primary outcome measurements complemented by additional secondary outcome parameters. RESULTS: The IG significantly increased functional performances in SPPB (total score: p = 0.012; chair rise: p = 0.007, balance: p = 0.066), reduced gait and balance deficits in POMA (total score: p = 0.006; balance: p = 0.034; gait: p = 0.019), and increased physical activity (APAFOP; p = 0.05) compared to the CG. Effect sizes showed medium to large effects for significant parameters (eta2 = 0.14-0.45). Training benefits and adherence were more pronounced following the immediate onset of post-ward training compared to a delayed start (eta2 = 0.06-0.23). CONCLUSION: Results of this pilot study show that a feasible and easy to handle, home-based rehabilitation program increased functional performance and physical activity in a vulnerable, multimorbid patient group with cognitive impairment, in particular when the post-ward training onset was not postponed.

Development of a home-based training program for post-ward geriatric rehabilitation patients with cognitive impairment: study protocol of a randomized-controlled trail.

BACKGROUND: Geriatric patients with cognitive impairment (CI) show an increased risk for a negative rehabilitation outcome and reduced functional recovery following inpatient rehabilitation. Despite this obvious demand, evidence-based training programs at the transition from rehabilitation to the home environments are lacking. The aim of this study is to evaluate the efficacy of a feasible and cost-effective home-based training program to improve motor performance and to promote physical activity, specifically-tailored for post-ward geriatric patients with CI. METHODS: A sample of 101 geriatric patients with mild to moderate stage CI following ward-based rehabilitation will be recruited for a blinded, randomized controlled trial with two arms. The intervention group will conduct a 12 week home-based training, consisting of (1) Exercises to improve strength/power, and postural control; (2) Individual walking trails to enhance physical activity; (3) Implementation of patient-specific motivational strategies to promote behavioral changes. The control group will conduct 12 weeks of unspecific flexibility exercise. Both groups will complete a baseline measurement before starting the program, at the end of the intervention, and after 24 weeks for follow-up. Sensor-based as well as questionnaire-based measures will be applied to comprehensively assess intervention effects. Primary outcomes document motor performance, assessed by the Short Physical Performance Battery, and level of physical activity (PA), as assessed by duration of active episodes (i.e., sum of standing and walking). Secondary outcomes include various medical, psycho-social, various PA and motor outcomes, including sensor-based assessment as well as cost effectiveness. DISCUSSION: Our study is among the first to provide home-based training in geriatric patients with CI at the transition from a rehabilitation unit to the home environment. The program offers several unique approaches, e.g., a comprehensive and innovative assessment strategy and the integration of individually-tailored motivational strategies. We expect the program to be safe and feasible in geriatric patients with CI with the potential to enhance the sustainability of geriatric rehabilitation programs in patients with CI. TRIAL REGISTRATION: International Standard Randomized Controlled Trial (# ISRCTN82378327 ). Registered: August 10, 2015.

Evaluation Studies of Robotic Rollators by the User Perspective: A Systematic Review.

BACKGROUND: Robotic rollators enhance the basic functions of established devices by technically advanced physical, cognitive, or sensory support to increase autonomy in persons with severe impairment. In the evaluation of such ambient assisted living solutions, both the technical and user perspectives are important to prove usability, effectiveness and safety, and to ensure adequate device application. OBJECTIVE: The aim of this systematic review is to summarize the methodology of studies evaluating robotic rollators with focus on the user perspective and to give recommendations for future evaluation studies. METHODS: A systematic literature search up to December 31, 2014, was conducted based on the Cochrane Review methodology using the electronic databases PubMed and IEEE Xplore. Articles were selected according to the following inclusion criteria: evaluation studies of robotic rollators documenting human-robot interaction, no case reports, published in English language. RESULTS: Twenty-eight studies were identified that met the predefined inclusion criteria. Large heterogeneity in the definitions of the target user group, study populations, study designs and assessment methods was found across the included studies. No generic methodology to evaluate robotic rollators could be identified. We found major methodological shortcomings related to insufficient sample descriptions and sample sizes, and lack of appropriate, standardized and validated assessment methods. Long-term use in habitual environment was also not evaluated. CONCLUSIONS: Apart from the heterogeneity, methodological deficits in most of the identified studies became apparent. Recommendations for future evaluation studies include: clear definition of target user group, adequate selection of subjects, inclusion of other assistive mobility devices for comparison, evaluation of the habitual use of advanced prototypes, adequate assessment strategy with established, standardized and validated methods, and statistical analysis of study results. Assessment strategies may additionally focus on specific functionalities of the robotic rollators allowing an individually tailored assessment of innovative features to document their added value.

Validity, Reliability, Responsiveness, and Feasibility of the Life-Space Assessment Administered via Telephone in Community-Dwelling Older Adults.

BACKGROUND AND OBJECTIVES: The life-space assessment (LSA) is the most commonly used questionnaire to assess life-space mobility (LSM) in older adults, with well-established psychometric properties for face-to-face (FF) administration. However, these properties have not yet been explicitly studied when the LSA is administered by telephone. The aim of this study was to evaluate the concurrent and construct validity, test-retest reliability, responsiveness, and feasibility of a telephone-based LSA version (TE-LSA) in older adults. RESEARCH DESIGN AND METHODS: Fifty community-dwelling older adults (age = 79.3 ± 5.3 years) participated in the study. Concurrent validity was assessed against the FF-LSA construct validity by testing 15 a priori hypotheses on expected associations with LSM determinants, test-retest reliability via 2 telephone surveys 1 week apart, responsiveness after 8.5 ± 1.8 months in participants with improved, stable, and worsened mobility defined by 2 external criteria, and feasibility by the completion rate/time and ceiling/floor effects. RESULTS: Good to excellent agreement between the 2 different administration methods was found (intraclass correlation coefficient [ICC2,1] = 0.73-0.98). Twelve of 15 (80%) hypotheses on construct validity were confirmed. ICCs for test-retest reliability were good to excellent (ICC2,1 = 0.62-0.94). Minimal detectable change for the TE-LSA total score was 20 points. Standardized response means were large for worsened (0.88), moderate for improved (0.68), and trivial for stable participants (0.04). Completion rate was 100% and mean completion time was 5.5 ± 3.3 min. No ceiling or floor effects were observed for the TE-LSA total score. DISCUSSION AND IMPLICATIONS: Telephone administration of the LSA is valid, reliable, responsive, and feasible for assessing LSM in community-dwelling older adults.

Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis.

BACKGROUND: No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population. OBJECTIVE: To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI. METHODS: In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention. RESULTS: Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%). CONCLUSIONS: Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.

Effects of a Home-Based Physical Training and Activity Promotion Program in Community-Dwelling Older Persons with Cognitive Impairment after Discharge from Rehabilitation: A Randomized Controlled Trial.

BACKGROUND: Older people with cognitive impairment (CI) are at high risk for mobility limitations and adverse outcomes after discharge from geriatric rehabilitation settings. The aim was to estimate the effects of a specifically designed home-based physical training and activity promotion program on physical capacity, different aspects of physical activity (PA), and psychosocial status. METHODS: Patients with mild to moderate CI (Mini-Mental State Examination [MMSE]: 17-26 points) discharged home after rehabilitation were included in this randomized, double-blind, placebo-controlled trial with a 12-week intervention and 12-week follow-up period. The intervention group performed a CI-specific, autonomous, home-based strength, balance, and walking training supported by tailored motivational strategies to foster training adherence and promote PA. The control group participated in an unspecific motor placebo activity. Primary outcomes were physical capacity (Short Physical Performance Battery [SPPB]) and PA (sensor-based activity time). RESULTS: Among 118 randomized participants (82.3 ± 6.0 years) with CI (MMSE: 23.3 ± 2.4) and high levels of multimorbidity, those participants undergoing home-based training demonstrated superior outcomes to the control group in SPPB (mean difference between groups 1.9 points; 95% CI: 1.0-2.8; p < .001), with persistent benefits over the follow-up (1.3 points; 95% CI: 0.4-2.2; p < .001). There were no differences in PA across any time points. Among secondary outcomes, fear of falling and activity avoidance behavior were reduced in the intervention group at all time points, life-space mobility improved short-term. CONCLUSIONS: The results demonstrate clinically important benefits of an individually tailored autonomous physical training and activity promotion program on physical capacity and secondary outcomes in different domains in a vulnerable, multimorbid population. CLINICAL TRIAL REGISTRATION: ISRCTN82378327.

Validation of the Life-Space Assessment (LSA-CI) in multi-morbid, older persons without cognitive impairment.

PURPOSE: The "Life-Space Assessment in Persons with Cognitive Impairment" (LSA-CI) to assess mobility within the environment including frequency and independence in 1 week has been developed for and successfully validated in older persons with mild to moderate cognitive impairment. However, its psychometric properties in persons without cognitive impairment are unknown. This study aims to validate the LSA-CI in older persons without cognitive impairment. METHODS: Comprehensive validation with construct validity, test-retest reliability and sensitivity to change of the LSA-CI including the main composite score and three sub-scores in community-dwelling older persons recruited during geriatric rehabilitation. RESULTS: Excellent feasibility with 100% completion rate and an average assessment duration of 4 min in 65 older, multimorbid persons (mean age: 81.4 ± 5.9 years; 72.3% female; average number of diagnoses: 11.1 ± 4.4). The LSA-CI composite score stood out with moderate to high construct validity (Spearman correlation coefficients |0.26|-|0.60|), excellent test-retest reliability (intraclass correlation coefficient 0.890) and moderate sensitivity to change (adjusted standardized response mean 0.70). Analysis of sub-scores confirmed most of the composite score results. CONCLUSIONS: The LSA-CI represents a valid, reliable, responsive, and highly feasible assessment method in multi-morbid, older persons without cognitive impairment, supporting the use of the LSA-CI in clinical practice and research.

Psychometric Properties of the Proxy-Reported Life-Space Assessment in Institutionalized Settings (LSA-IS-Proxy) for Older Persons with and without Cognitive Impairment.

(1) Background: Life-space mobility assessments for institutionalized settings are scarce and there is a lack of comprehensive validation and focus on persons with cognitive impairment (CI). This study aims to evaluate the psychometric properties of the Life-Space Assessment for Institutionalized Settings by proxy informants (LSA-IS-proxy) for institutionalized, older persons, with and without CI. (2) Methods: Concurrent validity against the self-reported version of the LSA-IS, construct validity with established construct variables, test-retest reliability, sensitivity to change during early multidisciplinary geriatric rehabilitation treatment, and feasibility (completion rate, floor/ceiling effects) of the LSA-IS-proxy, were assessed in 94 hospitalized geriatric patients (83.3 ± 6.1 years), with and without CI. (3) Results: The LSA-IS-proxy total score showed good-to-excellent agreement with the self-reported LSA-IS (Intraclass Correlations Coefficient, ICC3,1 = 0.77), predominantly expected small-to-high correlations with construct variables (r = 0.21-0.59), good test-retest reliability (ICC3,1 = 0.74), significant sensitivity to change over the treatment period (18.5 ± 7.9 days; p < 0.001, standardized response mean = 0.44), and excellent completion rates (100%) with no floor/ceiling effects. These results were predominantly confirmed for the sub-scores of the LSA-IS-proxy and were comparable between the sub-groups with different cognitive status. (4) Conclusions: The LSA-IS-proxy has proven to be feasible, valid, reliable, and sensitive to change in hospitalized, geriatric patients with and without CI.

Increasing Life-Space Mobility in Community-Dwelling Older Persons With Cognitive Impairment Following Rehabilitation: A Randomized Controlled Trial.

BACKGROUND: Community-dwelling older persons with cognitive impairment (CI) following discharge from geriatric rehabilitation are at high risk of losing life-space mobility (LSM). Interventions to improve their LSM are, however, still lacking. The aim of this study was to evaluate the effects of a CI-specific, home-based physical training and activity promotion program on LSM. METHODS: Older persons with mild-to-moderate CI (Mini-Mental State Examination: 17-26 points) discharged home from rehabilitation were included in this double-blinded, randomized, placebo-controlled trial with a 12-week intervention period and 12-week follow-up period. The intervention group received a CI-specific, home-based strength, balance, and walking training supported by tailored motivational strategies. The control group received a placebo activity. LSM was evaluated by the Life-Space Assessment in Persons with Cognitive Impairment, including a composite score for LSM and 3 subscores for maximal, equipment-assisted, and independent life space. Mixed-model repeated-measures analyses were used. RESULTS: One hundred eighteen participants (82.3 ± 6.0 years) with CI (Mini-Mental State Examination: 23.3 ± 2.4) were randomized. After the intervention, the home-based training program resulted in a significant benefit in the Life-Space Assessment in Persons with Cognitive Impairment composite scores (b = 8.15; 95% confidence interval: 2.89-13.41; p = .003) and independent life-space subscores (b = 0.39; 95% confidence interval: 0.00-0.78; p = .048) in the intervention group (n = 63) compared to control group (n = 55). Other subscores and follow-up results were not significantly different. CONCLUSIONS: The home-based training program improved LSM and independent life space significantly in this vulnerable population. Effects were not sustained over the follow-up. The program may represent a model for improved transition from rehabilitation to the community to prevent high risk of LSM restriction.

Promoting physical activity in geriatric patients with cognitive impairment after discharge from ward-rehabilitation: a feasibility study.

The aim of the present study was to examine adherence and acceptance of a home-based program to promote physical activity (PA) in older persons with cognitive impairment (CI) following inpatient rehabilitation. Sixty-three older persons (≥ 65 years) with mild to moderate CI (Mini-Mental State Examination score 17-26), allocated to the intervention group of a randomized, controlled intervention trial underwent a 12-week home-based PA intervention including (1) physical training and outdoor walking to improve functional fitness and (2) motivational strategies (goal-setting, pedometer-based self-monitoring, social support delivered by home visits, phone calls) to promote PA. Training logs were used to assess adherence to physical training, outdoor walking and to motivational strategies (goal-setting, pedometer-based self-monitoring). Acceptance (subjective feasibility and effectiveness) of the program components was assessed by a standardized questionnaire. Mean adherence rates over the intervention period were 63.6% for physical training, 57.9% for outdoor walking, and between 40.1% (achievement of walking goals), and 60.1% (pedometer-based self-monitoring) for motivational strategies. Adherence rates significantly declined from baseline to the end of intervention (T1: 43.4-76.8%, T2: 36.1-51.5%, p values<.019). Most participants rated physical training, outdoor walking, goal-setting, and pedometer self-monitoring as feasible (68.2-83.0%) and effective (63.5-78.3%). Highest ratings of self-perceived effectiveness were found for home visits (90.6%) and phone calls (79.2%). The moderate to high adherence to self-performed physical training and motivational strategies proved the feasibility of the home-based PA program in older persons with CI following inpatient rehabilitation.

Validation of a Modified Life-Space Assessment in Multimorbid Older Persons With Cognitive Impairment.

BACKGROUND AND OBJECTIVES: To investigate the validity, reliability, sensitivity to change, and feasibility of a modified University of Alabama at Birmingham Study of Aging Life-Space Assessment (UAB-LSA) in older persons with cognitive impairment (CI). RESEARCH DESIGN AND METHODS: The UAB-LSA was modified for use in persons with CI Life-Space Assessment for Persons with Cognitive Impairment (LSA-CI). Measurement properties of the LSA-CI were investigated using data of 118 multimorbid older participants with CI [mean age (SD): 82.3 (6.0) years, mean Mini-Mental State Examination score: 23.3 (2.4) points] from a randomized controlled trial (RCT) to improve motor performance and physical activity. Construct validity was asessed by Spearman's rank (rs) and point-biseral correlations (rpb) with age, gender, motor, and cognitive status, psychosocial factors, and sensor-derived (outdoor) physical activity variables. Test-retest reliability was analyzed using intra-class correlation coefficients (ICCs). Sensitivity to change was determined by standardized response means (SRMs) calculated for the RCT intervention group. RESULTS: The LSA-CI demonstrated moderate to high construct validity, with significant correlations of the LSA-CI scores with (outdoor) physical activity (rs = .23-.63), motor status (rs = .27-.56), fear of falling-related psychosocial variables (rs = |.24-.44|), and demographic characteristics (rpb = |.27-.32|). Test-retest reliability was good to excellent (ICC = .65-.91). Sensitivity to change was excellent for the LSA-CI composite score (SRM = .80) and small to moderate for the LSA-CI subscores (SRM = .35-.60). A completion rate of 100% and a mean completion time of 4.1 min) documented good feasibility. DISCUSSION AND IMPLICATIONS: The LSA-CI represents a valid, reliable, sensitive, and feasible interview-based life-space assessment tool in multimorbid older persons with CI.

Life-space mobility in older persons with cognitive impairment after discharge from geriatric rehabilitation.

OBJECTIVES: To describe life-space mobility and identify its determinants in older persons with cognitive impairment after discharge from geriatric rehabilitation. METHODS: A cross-sectional study in older community-dwelling persons with mild to moderate cognitive impairment (Mini-Mental State Examination, MMSE: 17-26) following geriatric rehabilitation was conducted. Life-space mobility (LSM) was evaluated by the Life-Space Assessment in Persons with Cognitive Impairment (LSA-CI). Bivariate analyses and multivariate regression analyses were used to investigate associations between LSM and physical, cognitive, psychosocial, environmental, financial and demographic characteristics, and physical activity behavior. RESULTS: LSM in 118 older, multimorbid participants (age: 82.3 ± 6.0 years) with cognitive impairment (MMSE score: 23.3 ± 2.4 points) was substantially limited, depending on availability of personal support and equipment. More than 30% of participants were confined to the neighborhood and half of all patients could not leave the bedroom without equipment or assistance. Motor performance, social activities, physical activity, and gender were identified as independent determinants of LSM and explained 42.4% (adjusted R²) of the LSA-CI variance in the regression model. CONCLUSION: The study documents the highly restricted LSM in older persons with CI following geriatric rehabilitation. The identified modifiable determinants of LSM show potential for future interventions to increase LSM in such a vulnerable population at high risk for restrictions in LSM by targeting motor performance, social activities, and physical activity. A gender-specific approach may help to address more advanced restrictions in women.

Validity, reliability, and feasibility of the uSense activity monitor to register physical activity and gait performance in habitual settings of geriatric patients.

OBJECTIVE: The aim of the study was to investigate the psychometric quality of a newly developed activity monitor (uSense) to document established physical activity parameters as well as innovative qualitative and quantitative gait characteristics in geriatric patients. APPROACH: Construct and concurrent validity, test-retest reliability, and feasibility of established as well as innovative characteristics for qualitative gait analysis were analyzed in multi-morbid, geriatric patients with cognitive impairment (CI) (n = 110), recently discharged from geriatric rehabilitation. MAIN RESULTS: Spearman correlations of established and innovative uSense parameters reflecting active behavior with clinically relevant construct parameters were on average moderate to high for motor performance and life-space and low to moderate for other parameters, while correlations with uSense parameters reflecting inactive behavior were predominantly low. Concurrent validity of established physical activity parameters showed consistently high correlations between the uSense and an established comparator system (PAMSys™), but the absolute agreement between both sensor systems was low. On average excellent test-retest reliability for all uSense parameters and good feasibility could be documented. SIGNIFICANCE: The uSense monitor allows the assessment of established and-for the first time-a semi-qualitative gait assessment of habitual activity behavior in older persons most affected by motor and CI and activity restrictions. On average moderate to good construct validity, high test-retest reliability, and good feasibility indicated a sound psychometric quality of most measures, while the results of concurrent validity as measured by a comparable system indicated high correlation but low absolute agreement based on different algorithms used.

A systematic review of study results reported for the evaluation of robotic rollators from the perspective of users.

PURPOSE: To evaluate the effectiveness and perception of robotic rollators (RRs) from the perspective of users. METHODS: Studies identified in a previous systematic review published on 2016 on the methodology of studies evaluating RRs by the user perspective were re-screened for eligibility based on the following inclusion criteria: evaluation of the human-robot interaction from the user perspective, use of standardized outcome measurements, and quantitative presentation of study results. RESULTS: Seventeen studies were eligible for inclusion. Due to the clinical and methodological heterogeneity across studies, a narrative synthesis of study results was conducted. We found conflicting results concerning the effectiveness of the robotic functionalities of the RRs. Only a few studies reported superior user performance or reduced physical demands with the RRs compared to unassisted conditions or conventional assistive mobility devices; however, without providing statistical evidence. The user perception of the RRs was found to be generally positive. CONCLUSIONS: There is still no sufficient evidence on the effectiveness of RRs from the user perspective. More well-designed, high-quality studies with adequate study populations, larger sample sizes, appropriate assessment strategies with outcomes specifically tailored to the robotic functionalities, and statistical analyses of results are required to evaluate RRs at a higher level of evidence. Implications for Rehabilitation RRs cover intelligent functionalities that focus on gait assistance, obstacle avoidance, navigation assistance, sit-to-stand transfer, body weight support or fall prevention. The evaluation from the user perspective is essential to ensure that RRs effectively address users' needs, requirements and preferences. The evidence on the effectiveness of RRs is severely hampered by the low methodological quality of most of the available studies. RRs seem generally to be perceived as positive by the users. There is very limited evidence on the effectiveness and benefits of RRs compared to conventional assistive mobility devices. Further research with high methodological quality needs to be conducted to reach more robust conclusions about the effectiveness of RRs.