Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care.

BACKGROUND: Regular physical activity (PA) reduces the risk of falls and hip fractures, and mortality from all causes. However, PA levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements. OBJECTIVE: To evaluate the impact of two exercise promotion programmes on PA in people aged ≥ 65 years. DESIGN: The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged ≥ 65 years) in primary care. SETTING: Forty-three UK-based general practices in London and Nottingham/Derby. PARTICIPANTS: A total of 1256 people ≥ 65 years were recruited through their general practices to take part in the trial. INTERVENTIONS: The FaME programme and OEP. FaME included weekly classes plus home exercises for 24 weeks and encouraged walking. OEP included home exercises supported by peer mentors (PMs) for 24 weeks, and encouraged walking. MAIN OUTCOME MEASURES: The primary outcome was the proportion that reported reaching the recommended PA target of 150 minutes of moderate to vigorous physical activity (MVPA) per week, 12 months after cessation of the intervention. Secondary outcomes included functional assessments of balance and falls risk, the incidence of falls, fear of falling, quality of life, social networks and self-efficacy. An economic evaluation including participant and NHS costs was embedded in the clinical trial. RESULTS: In total, 20,507 patients from 43 general practices were invited to participate. Expressions of interest were received from 2752 (13%) and 1256 (6%) consented to join the trial; 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. Primary outcome data were available at 12 months after the end of the intervention period for 830 (66%) of the study participants. The proportions reporting at least 150 minutes of MVPA per week rose between baseline and 12 months after the intervention from 40% to 49% in the FaME arm, from 41% to 43% in the OEP arm and from 37.5% to 38.0% in the usual-care arm. A significantly higher proportion in the FaME arm than in the usual-care arm reported at least 150 minutes of MVPA per week at 12 months after the intervention [adjusted odds ratio (AOR) 1.78, 95% confidence interval (CI) 1.11 to 2.87; p = 0.02]. There was no significant difference in MVPA between OEP and usual care (AOR 1.17, 95% CI 0.72 to 1.92; p = 0.52). Participants in the FaME arm added around 15 minutes of MVPA per day to their baseline physical activity level. In the 12 months after the close of the intervention phase, there was a statistically significant reduction in falls rate in the FaME arm compared with the usual-care arm (incidence rate ratio 0.74, 95% CI 0.55 to 0.99; p = 0.042). Scores on the Physical Activity Scale for the Elderly showed a small but statistically significant benefit for FaME compared with usual care, as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months post intervention in both arms compared with the usual-care arm. There were no statistically significant differences between intervention arms and the usual-care arm in other secondary outcomes, including quality-adjusted life-years. FaME is more expensive than OEP delivered with PMs (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham). The cost per extra person exercising at, or above, target was £1919.64 in London and £1560.21 in Nottingham (mean £1739.93). CONCLUSION: The FaME intervention increased self-reported PA levels among community-dwelling older adults 12 months after the intervention, and significantly reduced falls. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms. TRIAL REGISTRATION: This trial is registered as ISRCTN43453770. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 49. See the NIHR Journals Library website for further project information.

Completion and return of fall diaries varies with participants' level of education, first language, and baseline fall risk.

BACKGROUND: Consensus guidelines recommend the use of prospective fall diaries in studies of fall rates. We sought to determine the characteristics associated with return and successful completion of a falls diary and whether characteristics such as gender, education level, native language, income, and falls risk influenced self-reported fall rates. METHODS: Two hundred and seventy people aged 65 years and older participating in a randomized controlled trial evaluating two exercise programmes. Fall diaries were collected for 6 months, then evaluated for correct completion and falls reported. RESULTS: An increasing risk of falls was associated with a reducing odds of returning diaries (odds ratio for a one unit increase in Falls Risk Assessment Tool score 0.71, 95% confidence interval 0.53-0.96). Native English speakers were more likely to complete more than half the diaries correctly (odds ratio 2.63, 95% confidence interval 1.20-5.75). CONCLUSIONS: Problems arise in the correct completion of falls diaries among those for whom English is not their first language. Diaries may underreport the rate of falls as those at higher risk were less likely to return diaries but more likely to report falls. Careful consideration should be given to the analysis of falls diaries as missing data are unlikely to be missing completely at random. We recommend additional training in the use of falls diaries for these groups or the utilization of simpler instruments.

Activity promotion for community-dwelling older people: a survey of the contribution of primary care nurses.

STUDY AIMS: To discover the current level of nurse-led involvement in activity promotion for older people in primary care and to explore the knowledge and attitudes of primary care nurses about health benefits of activity promotion for older people. BACKGROUND: The importance of improving and maintaining activity levels in later life is well established. However, intervention studies show that the uptake of and adherence to physical activity programmes by older people are highly variable. The optimal approach to activity promotion for older people is not well understood. Although many activity promotion schemes and evaluations assume that specialist exercise trainers are needed, it remains unclear who is best placed to facilitate activity promotion for older people, and if this is something in which existing primary care practitioners (specifically nurses) could and should take a leading role. METHODS: This study surveyed all nurses and health visitors working in five primary care organizations in an inner city area. A semi-structured postal questionnaire asked about their knowledge and attitudes to the benefits of exercise in later life, their current levels of involvement in promoting physical activity with older people, and their personal activity levels. FINDINGS: The overall response rate was 54% (n=521). The responses of 391 district nurses and practice nurses are presented here. Nurses had the commitment and (depending on the focus of their work) different opportunities to promote physical activity with older patients. There were organizational and individual constraints on their ability to be involved in this aspect of health promotion work themselves, or to refer older people to local activity promotion schemes. Nurses did not have a structured approach when promoting physical activity with older people and had only a partial awareness of the limitations of their knowledge or skills when promoting activity with older people. CONCLUSIONS: For promotion of physical activity by older people to be meaningfully incorporated into primary care nursing work there is a need to develop a more strategic approach that can optimize the opportunities and interest of primary care nurses and develop the knowledge and skills of the workforce in this area of nursing work.

Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: protocol of the ProAct 65+ trial.

BACKGROUND: Regular physical activity reduces the risk of mortality from all causes, with a powerful beneficial effect on risk of falls and hip fractures. However, physical activity levels are low in the older population and previous studies have demonstrated only modest, short-term improvements in activity levels with intervention. DESIGN/METHODS: Pragmatic 3 arm parallel design cluster controlled trial of class-based exercise (FAME), home-based exercise (OEP) and usual care amongst older people (aged 65 years and over) in primary care. The primary outcome is the achievement of recommended physical activity targets 12 months after cessation of intervention. Secondary outcomes include functional assessments, predictors of exercise adherence, the incidence of falls, fear of falling, quality of life and continuation of physical activity after intervention, over a two-year follow up. An economic evaluation including participant and NHS costs will be embedded in the clinical trial. DISCUSSION: The ProAct65 trial will explore and evaluate the potential for increasing physical activity among older people recruited through general practice. The trial will be conducted in a relatively unselected population, and will address problems of selective recruitment, potentially low retention rates, variable quality of interventions and falls risk. TRIAL REGISTRATION: Trial Registration: ISRCTN43453770.

Stroke: a randomized trial of exercise or relaxation.

OBJECTIVES: To determine the feasibility and effect of exercise training after stroke. DESIGN: Randomized exploratory trial comparing exercise training (including progressive endurance and resistance training) with relaxation (attention control). SETTING: Interventions were performed in a rehabilitation hospital. PARTICIPANTS: Sixty-six independently ambulatory patients (mean age 72, 36 men) without significant dysphasia, confusion, or medical contraindications to exercise training who had completed their usual rehabilitation and had been discharged from hospital. INTERVENTION: Both interventions were held three times a week for 12 weeks. Up to seven patients attended each session. MEASUREMENTS: The Functional Independence Measure; Nottingham Extended Activities of Daily Living; Rivermead Mobility Index; functional reach; sit-to-stand; elderly mobility score; timed up-and-go; Medical Outcomes Study 36-Item Short Form Questionnaire, version 2 (SF-36); Hospital Anxiety and Depression Score; aspects of physical fitness (comfortable walking speed, walking economy, and explosive leg extensor power) were measured at baseline, immediately after interventions (3 months), and 7 months after baseline. RESULTS: The median number of intervention sessions attended was 36 (interquartile range (IQR) 30.00-36.75) for exercise and 36 (IQR 30.50-37.00) for relaxation. Adherence to the individual exercises ranged from 94% to 99%. At 3 months, role-physical (an item in SF-36), timed up-and-go, and walking economy were significantly better in the exercise group (analysis of covariance). At 7 months, role-physical was the only significant difference between groups. CONCLUSION: Exercise training for ambulatory stroke patients was feasible and led to significantly greater benefits in aspects of physical function and perceived effect of physical health on daily life.

Is the promotion of physical activity in vulnerable older people feasible and effective in general practice?

There is convincing evidence about the benefits of exercise training in community dwelling frailer older people, but little evidence that this intervention can be delivered in general practice. In this prospective cohort study in 14 general practices in north London we assessed the feasibility and effectiveness of a tailored exercise referral programme for frail elderly patients delivered within a variety of inner city primary care settings. One hundred and twenty-six women and 32 men aged 75 years and older, deemed borderline frail by their GPs, took part in a two-phase progressive exercise programme (Stage 1--primary care setting; Stage II--leisure/community centre setting) using the Timed Up And Go (TUG) test as the primary outcome measure. Baseline TUG measures confirmed that the participants were borderline frail and that GP selection was accurate. Of those referred by their GP or practice nurse 89% took up the exercise programme; 73% completed Stage I and 63% made the transition to the community Stage II programme. TUG improved in Stage I with a mean difference of 3.5 seconds (P<0.001). An individually tailored progressive exercise programme following GP referral, delivered in weekly group sessions by specialist exercise instructors within general practices, was effective in achieving participation in exercise sessions and in improving TUG values in a significant number of frailer older citizens.

Aerobic training in the 'oldest old': the effect of 24 weeks of training.

OBJECTIVE: to determine the effects of aerobic training on the maximal aerobic power of healthy, very elderly people. DESIGN: a 12-week control period followed by 24 weeks of progressive, weight bearing, aerobic training. SUBJECTS: 26 men and women aged 79 to 91 years conforming to pre-determined health criteria. METHODS: we took measurements before and after a 12 week control period and following 24 weeks of training. These were maximal aerobic power (VO(2)max), heart rate at an oxygen consumption of 10 ml x kg(-1) x min(-1) (HR at VO(2)10), resting heart rate, isometric knee extensor strength, isometric elbow flexor strength and lower limb extensor power. MAIN RESULTS: pre-control values of VO(2)max for the women and men were 14.1 (SD 2.79) and 22.0 (5.12) ml.kg(-1).min(-1) respectively. There was no significant change in the VO(2)max of either group over the control period. After training, there was a 15% increase in the VO(2)max of the women (P<0.01) but no change was observed in the men. In the women, there was no significant change in HR at VO(2)10 over the control period but a 14% decrease (P<0.01) after training. In the men there was a 7% (P<0.05) increase in HR at VO(2)10 over the control period and a 5% (P<0.05) decrease after training. No effect of training was seen on isometric knee extensor strength, isometric elbow flexor strength or lower limb extensor power of either group. CONCLUSION: progressive aerobic training can increase the maximal aerobic power of very elderly women. A 15% increase in VO(2)max may prevent many elderly women from crossing functionally important thresholds, thereby helping to maintain independence.