Implementation of a digital exercise programme in health services to prevent falls in older people.

BACKGROUND: StandingTall uses eHealth to deliver evidence-based balance and functional strength exercises. Clinical trials have demonstrated improved balance, reduced falls and fall-related injuries and high adherence. This study aimed to evaluate the implementation of StandingTall into health services in Australia and the UK. METHODS: Two hundred and forty-six participants (Australia, n = 184; UK, n = 62) were recruited and encouraged to use StandingTall for 2 h/week for 6-months. A mixed-methods process evaluation assessed uptake and acceptability of StandingTall. Adherence, measured as % of prescribed dose completed, was the primary outcome. RESULTS: The study, conducted October 2019 to September 2021 in Australia and November 2020 to April 2022 in the UK, was affected by COVID-19. Participants' mean age was 73 ± 7 years, and 196 (81%) were female. Of 129 implementation partners (e.g. private practice clinicians, community exercise providers, community service agencies) approached, 34% (n = 44) agreed to be implementation partners. Of 41 implementation partners who referred participants, 15 (37%) referred ≥5. Participant uptake was 42% (198/469) with mean adherence over 6 months being 41 ± 39% of the prescribed dose (i.e. 39 ± 41 min/week) of exercise. At 6 months, 120 (76%) participants indicated they liked using StandingTall, 89 (56%) reported their balance improved (moderately to a great deal better) and 125 (80%) rated StandingTall as good to excellent. For ongoing sustainability, health service managers highlighted the need for additional resources. CONCLUSIONS: StandingTall faced challenges in uptake, adoption and sustainability due to COVID-19 and a lack of ongoing funding. Adherence levels were lower than the effectiveness trial, but were higher than other exercise studies. Acceptance was high, indicating promise for future implementation, provided sufficient resources and support are made available. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12619001329156.

A Wrist-Worn Wearable Device Can Identify Frailty in Middle-Aged and Older Adults: The UK Biobank Study.

OBJECTIVES: Digital gait biomarkers collected from body-worn devices can remotely and continuously collect movement types, quantity, and quality in real life. This study assessed whether digital gait biomarkers from a wrist-worn device could identify people with frailty in a large sample of middle-aged and older adults. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: A total of 5822 middle-aged (43-64 years) and 4344 older adults (65-81 years) who participated in the UK Biobank study. MEASURES: Frailty was assessed using a modified Fried's frailty assessment and was defined as having ≥3 of the 5 frailty criteria (weakness, low activity levels, slowness, exhaustion, and weight loss). Fourteen digital gait biomarkers were extracted from accelerometry data collected from wrist-worn sensors worn continuously by participants for up to 7 days. RESULTS: A total of 238 (4.1%) of the middle-aged group and 196 (4.5%) of the older group were categorized as frail. Multivariable logistic regression analysis revealed that less daily walking (as assessed by step counts), slower maximum walking speed, and increased step time variability best-identified people with frailty in the middle-aged group (area under the curve [95% CI]: 0.70 [0.66-0.73]). Less daily walking, slower maximum walking speed, increased step time variability, and a lower proportion of walks undertaken with a manual task best-identified people with frailty in the older group (0.73 [0.69-0.76]). CONCLUSIONS AND IMPLICATIONS: Our findings indicate that measures obtained from wrist-worn wearable devices worn in everyday life can identify individuals with frailty in both middle-aged and older people. These digital gait biomarkers may facilitate screening programs and the timely implementation of frailty-prevention interventions.

Vitamin D supplementation and falls in residential aged care: A longitudinal multisite cohort study.

Background: Vitamin D is vital for musculoskeletal health, and supplementation may lower risk of falls. Past research in residential aged care (RAC) settings on the effects of vitamin D on falls have reported inconclusive findings, partly due to study design limitations. We utilised a longitudinal study design to assess the association between the use of vitamin D and falls over 36 months in RAC. Method: A longitudinal cohort study was conducted using routinely collected electronic data spanning 9 years from 27 RAC facilities in Sydney, New South Wales, Australia. The study included 4520 permanent residents aged 65 years or older who were admitted for the first time from 1 July 2014 and stayed for a minimum of one month. We identified daily vitamin D usage over 36 months, and measured adherence using the Proportion of Days Covered (PDC) metric. A PDC value of ≥80 % signifies optimal adherence. Primary outcomes were the number of all falls and injurious falls. A rolling time-varying predictor-outcome approach and Generalized Estimating Equations (GEE) were applied to determine the longitudinal link between vitamin D supplement use and subsequent risk of falls. Results: Over two-thirds of residents (67.8 %; n = 3063) received vitamin D supplements during their stay, with a median PDC of 74.8 % among users, and 44.6 % (n = 1365) achieving optimal adherence. Increasing age, osteoporosis or fracture history, and dementia were associated with a greater likelihood of achieving optimal adherence. Crude fall incident rates were 8.05 and 2.92 incidents per 1000 resident days for all falls and injurious falls respectively. After accounting for relevant demographic and clinical factors, no significant links were observed between vitamin D supplement usage and fall outcomes: all falls (Incident Rate Ratio [IRR] 1.01; 95 % CI 1.00-1.02; P = 0.237) and injurious falls (IRR 1.01; 95 % CI 1.00-1.02; P = 0.091). Conclusion: Vitamin D supplementation was not associated with a reduced risk of falls, suggesting it is not an effective intervention for preventing falls in RAC. While clinicians should ensure adequate vitamin D intake for residents' nutritional and bone health, it should not be a standalone falls prevention intervention in RAC populations.

The Impact of Misaligned Perceived and Objective Fall Risk in Cognitively Impaired Older People.

Background: Cognitive impairment (CI) may impair the ability to accurately perceive physical capacity and fall risk. Objective: We investigated perceived (measured as concern about falls) and physiological fall risk in community-dwelling older people with CI, the characteristics of the aligned and misaligned groups and the impact of misaligned perceptions on falls. Methods: Participants (n= 293) with mild-moderate CI were classified into four groups based on validated physiological and perceived fall risk assessments: 1) vigorous: low perceived and physiological fall risk; 2) anxious: high perceived and low physiological fall risk; 3) unaware: low perceived and high physiological fall risk; and 4) aware: high perceived and physiological fall risk. Groups were compared with respect to neuropsychological and physical function, activity and quality of life measures, and prospective falls (12-months). Results: The anxious (IRR = 1.70, 95% CI = 1.02-2.84), unaware (IRR = 2.00, 95% CI = 1.22-3.26), and aware (IRR = 2.53, 95% CI = 1.67-3.84) groups had significantly higher fall rates than the vigorous group but fall rates did not significantly differ among these groups. Compared with the vigorous group: the anxious group had higher depression scores and reduced mobility and quality of life; the unaware group had poorer global cognition, executive function and mobility and lower physical activity levels; and the aware group had an increased prevalence of multiple physical and cognitive fall risk factors. Conclusions: Fall rates were increased in participants who had increased perceived and/or physiological fall risk. Contrasting fall risk patterns were evident in those who under- and over-estimated their fall risk. Understanding these characteristics will help guide fall risk assessment and prevention strategies in community-dwelling older people with CI.

A Longitudinal Study of the Use and Effects of Fall-Risk-Increasing Drugs in Residential Aged Care.

OBJECTIVES: Fall-risk-increasing drugs (FRIDs)-psychotropics and cardiovascular disease (CVD) drugs-may elevate the risk of falling, with strong evidence observed in psychotropic FRIDs, whereas findings from cardiovascular disease (CVD) FRIDs remain inconclusive. Existing studies on FRIDs and falls are often hampered by methodologic limitations. Leveraging longitudinal observational data, we aimed to determine the long-term patterns of FRID use and their association with falls in residential aged care (RAC) homes. DESIGN: A retrospective longitudinal cohort study. SETTING AND PARTICIPANTS: A total of 4207 permanent residents newly admitted to 27 RAC homes in Sydney, Australia. METHOD: The outcomes were incidence of all and injurious falls. We measured exposure to each FRID over 60 months using the Proportion of Days Covered (PDC) metric. We used group-based multitrajectory modeling to determine concurrent usage patterns of psychotropics and CVD FRIDs and applied negative binomial regression to assess their associations with the outcomes. RESULTS: A total of 83.6% (n = 3516) and 77.3% (n = 3254) residents used psychotropic and CVD FRIDs, respectively. The PDC values ranged from 67.3% (opioids) to 86.9% (antidepressants) for specific psychotropics and 79.0% (α-adrenoceptor antagonists) to 89.6% (ß blockers) for CVD FRIDs. We identified 4 groups: group 1, low psychotropics-low CVDs use (16.7%, n = 701); group 2, low psychotropics-high CVDs (25.0%, n = 1054); group 3, high psychotropics-high CVDs (41.0%, n = 1723); and group 4, high psychotropics-low CVDs (17.3%, n = 729). Group 4 had a significantly higher rate of falls than the other groups for both outcomes, including relative to group 3, in which exposure to both FRID classes was high. CONCLUSIONS AND IMPLICATIONS: Our findings reveal concerningly high FRID use in RAC homes and highlight a critical difference in the impact of the 2 major FRID classes on falls. Psychotropics were strongly associated with falls, whereas the studied CVD FRIDs did not elevate risk of falling.

Ladder Use Ability, Behavior and Exposure by Age and Gender.

This study aimed to quantify and compare ladder use ability and behavior in younger and older men and women from three ladder use behavior experiments. The experimental tasks comprised (1) changing a lightbulb on a household stepladder under two cognitive demands (single and dual task), (2) clearing a simulated roof gutter on a straight ladder and (3) querying ladder choice in different exigency scenarios. Ladder use ability and behavior data were captured from recorded time, performance, motion capture and user choice data. In addition, this study surveyed ladder use frequency and habitual behaviors. The experimental findings indicate that older adults require more time to complete ladder tasks; younger adults display riskier ladder use behaviors; men and women display similar ladder use ability; and men are more willing to climb riskier ladders. The survey found older adults to report more frequent ladder use than younger adults, and men use straight ladders more frequently than women. These results suggest that the reported higher ladder fall rates experienced by older adults and men are linked to increased ladder use exposure and riskier ladder choice. This knowledge can help guide population-specific interventions to reduce ladder falls in both young and older people.

Development, Validation, and Limits of Freezing of Gait Detection Using a Single Waist-Worn Device.

OBJECTIVE: Freezing of Gait (FOG) often described as the sensation of "the feet being glued to the ground" is prevalent in people with Parkinson's disease (PD) and severely disturbs mobility. In addition to tracking disease progression, precise detection of the exact boundaries for each FOG episode may enable new technologies capable of "breaking" FOG in real time. This study investigates the limits of sensitivity and performance for automatic device-based FOG detection. METHODS: Eight machine-learning classifiers (including Neural Networks, Ensemble & Support Vector Machine) were developed using (i) accelerometer and (ii) accelerometer and gyroscope data from a waist-worn device. While wearing the device, 107 people with PD completed a walking and mobility task designed to elicit FOG. Two clinicians independently annotated the precise FOG episodes using synchronized video according to international guidelines, which were incorporated into a flowchart algorithm developed for this study. Device-detected FOG episodes were compared to the annotated FOG episodes using 10-fold cross-validation to determine accuracy and with Interclass Correlation Coefficients (ICC) to assess level of agreement. RESULTS: Development used 50,962 windows of data representing over 10 hours of data and annotated activities. Very strong agreement between clinicians for precise FOG episodes was observed (90% sensitivity, 92% specificity and ICC1,1  =  0.97 for total FOG duration). Device-based performance varied by method, complexity and cost matrix. The Neural Network that used only 67 accelerometer features provided a good balance between high sensitivity to FOG (89% sensitivity, 81% specificity and ICC1,1  =  0.83) and solution stability (validation loss ≤ 5%). CONCLUSION: The waist-worn device consistently reported accurate detection of precise FOG episodes and compared well to more complex systems. The superior agreement between clinicians indicates there is room to improve future device-based FOG detection by using larger and more varied data sets. SIGNIFICANCE: This study has clinical implications with regard to improving PD care by reducing reliance on clinical FOG assessments and time-consuming visual inspection. It shows high sensitivity to automatically detect FOG is possible.

Brain and brawn in balance: Central processing speed and muscle torque development speed are independently associated with the ability to recover balance with feet-in-place.

BACKGROUND: Stepping thresholds, i.e. the maximum perturbation one can withstand without taking a step, predict falls in older people. This ability requires fast central processing of sensory information followed by rapid execution of adequate motor responses, both of which are affected by age. However, there is limited evidence on their combined effect on stepping thresholds. RESEARCH QUESTION: Are cognitive and motor speeds important for stepping thresholds and do they interact, allowing for compensation? METHODS: Two-hundred forty-two people (mean age: 80 years, standard deviation 4; 110 women) underwent a series of waist-pulls of increasing magnitude to assess stepping thresholds in anterior, posterior and mediolateral directions. Cognitive function was assessed as simple hand reaction time and trail making test performance, and muscle function was assessed as isometric peak and rate of torque development of dominant leg muscles. Principal component analysis reduced these variables to four factors: peak muscle strength, muscle torque development speed (motor speed), executive function and central processing speed (cognitive speed). These factors were used in univariable and multivariable regression models to determine their association with stepping thresholds. RESULTS: Faster central processing speed (beta:2.69; 95 %CI:1.49-3.88) and faster muscle torque development speed (beta:2.60, 95 %CI:0.63-4.57) were associated with higher stepping thresholds. These associations remained in a multivariable model. No interaction was found between cognitive and motor speed on stepping thresholds (p = 0.602). SIGNIFICANCE: Central processing speed and muscle torque development speed affect stepping thresholds independently from each other and may both be important age-related motor impairment targets for preventing falls in older people.

A custom-built step exergame training programme to prevent falls in people with multiple sclerosis: A multicentre randomised controlled trial.

BACKGROUND: Cognitive-motor step training can improve stepping, balance and mobility in people with multiple sclerosis (MS), but effectiveness in preventing falls has not been demonstrated. OBJECTIVES: This multisite randomised controlled trial aimed to determine whether 6 months of home-based step exergame training could reduce falls and improve associated risk factors compared with usual care in people with MS. METHODS: In total, 461 people with MS aged 22-81 years were randomly allocated to usual care (control) or unsupervised home-based step exergame training (120 minutes/week) for 6 months. The primary outcome was rate of falls over 6 months from randomisation. Secondary outcomes included physical, cognitive and psychosocial function at 6 months and falls over 12 months. RESULTS: Mean (standard deviation (SD)) weekly training duration was 70 (51) minutes over 6 months. Fall rates did not differ between intervention and control groups (incidence rates (95% confidence interval (CI)): 2.13 (1.57-2.69) versus 2.24 (1.35-3.13), respectively, incidence rate ratio: 0.96 (95% CI: 0.69-1.34, p = 0.816)). Intervention participants performed faster in tests of choice-stepping reaction time at 6 months. No serious training-related adverse events were reported. CONCLUSION: The step exergame training programme did not reduce falls among people with MS. However, it significantly improved choice-stepping reaction time which is critical to ambulate safely in daily life environment.

Protocol of a 12-week eHealth programme designed to reduce concerns about falling in community-living older people: Own Your Balance randomised controlled trial.

INTRODUCTION: Concerns about falling (CaF) are common in older people and have been associated with avoidance of activities of daily life. Exercise designed to prevent falls can reduce CaF, but the effects are usually short-lived. Cognitive behavioural therapy (CBT) can reduce CaF for longer but is not readily available in the community and unlikely to prevent falls. A multidomain intervention that combines CBT, motivational interviewing and exercise could be the long-term solution to treat CaF and reduce falls in older people with CaF. This paper describes the design of a randomised controlled trial to test the effectiveness of two different 12 week self-managed eHealth programmes to reduce CaF compared with an active control. METHODS: A total of 246 participants (82 per group) aged 65 and over, with substantial concerns about falls or balance will be recruited from the community. They will be randomised into: (1) myCompass-Own Your Balance (OYB) (online CBT programme) intervention or (2) myCompass-OYB plus StandingTall intervention (an eHealth balance exercise programme), both including motivational interviewing and online health education or (3) an active control group (online health education alone). The primary outcome is change in CaF over 12 months from baseline of both intervention groups compared with control. The secondary outcomes at 2, 6 and 12 months include balance confidence, physical activity, habitual daily activity, enjoyment of physical activity, social activity, exercise self-efficacy, rate of falls, falls health literacy, mood, psychological well-being, quality of life, exercise self-efficacy, programme adherence, healthcare use, user experience and attitudes towards the programme. An intention-to-treat analysis will be applied. The healthcare funder's perspective will be adopted for the economic evaluation if appropriate. ETHICS AND DISSEMINATION: Ethical approval was obtained from the South Eastern Sydney Local Health District Human Research Ethics Committee (2019/ETH12840). Results will be disseminated via peer-reviewed journals, local and international conferences, community events and media releases. TRIAL REGISTRATION NUMBER: ACTRN12621000440820.

Treadmill induced belt-accelerations may not accurately evoke the muscle responses to obstacle trips in older people.

BACKGROUND: Treadmill belt-accelerations are a commonly utilised surrogate for tripping, but their physiological validity is unknown. This study examined if a treadmill belt-acceleration induces lower limb muscle activation responses similar to a trip on a walkway. METHODS: 38 older people (65+ years) experienced one treadmill belt-acceleration and one walkway obstacle trip in random order. Muscle responses were assessed bilaterally using surface electromyography on the rectus femoris (RF), tibialis anterior (TA), semitendinosus (ST) and gastrocnemius medial head (GM). Unperturbed muscle activity, post-perturbation onset latency, peak magnitude, time to peak and co-contraction index (CCI) were examined. RESULTS: Muscle activity in the right ST was greater during unperturbed walking on the treadmill compared to walkway (P=0.011). Compared to a treadmill belt-acceleration, a walkway trip elicited faster onset latencies in all muscles; greater peak magnitudes in the left RF, TA, GM and right GM; faster time to peaks in the left TA and right GM; and lower knee and ankle muscle CCI (P<0.05). CONCLUSIONS: Walkway trips and treadmill belt-accelerations elicit distinct muscle activation patterns. While walkway trips induced faster and larger muscle responses, treadmill belt-accelerations involved greater co-contraction. Therefore, treadmill belt-accelerations may not accurately simulate the muscle responses to trips.

Effect of cognitive training on cognitive function in community-dwelling older people with mild-to-moderate dementia: A single-blind randomised controlled trial.

OBJECTIVES: The purpose of this assessor-blinded, randomised controlled trial was to determine the effect of computerised cognitive training (CT) on executive function, processing speed and working memory in 61 people with mild-to-moderate dementia. METHODS: The primary outcomes were forward Digit Span and Trail Making Tests (TMT) at the completion of the 6-month intervention. Secondary outcomes included cognitive and physical performance, rate of falls, participant and caregiver's quality of life and usability and adherence to the CT program. The study was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12617000364370). RESULTS: Intervention group (n = 31) participants averaged 81 min of CT per week, and system usability scores were acceptable (participants: 68.8 ± 22.1; caregivers: 79.4 ± 23.5). There were no statistically significant differences in cognitive or physical performance outcomes between the intervention and control groups at 6- or 12-months (between-group differences [95% CI] for primary outcomes at 6-months: Forward Digit Span -0.3 [-0.8, 0.3]; TMT-A 2.7 s [-14.1, 19.5]; TMT-B -17.1 s [-79.3, 45.2]). At the 12-month follow-up reassessment, the intervention group reported significantly more depressive symptoms and had lower caregiver-rated participant quality of life and higher caregiver quality of life compared to control. CONCLUSIONS: This study showed no benefit of the CT program on working memory, processing speed and executive function. Future studies are required to better understand how CT can be used to improve cognitive and physical functioning in older people with mild-moderate dementia.

Poor mobility and lower limb weakness are associated with three distinct depressive symptom trajectories over 6 years in older people.

OBJECTIVES: Physical decline can be associated with the onset of depressive symptoms in later life. This study aimed to identify physical and lifestyle risk factors for depressive symptom trajectories in community-dwelling older adults. METHODS: Participants were 553 people aged 70-90 years who underwent baseline physical, psychological and lifestyle assessments. Group-based trajectory analysis was used to identify patterns of depressive symptom development over 6 years of follow-up. Strengths of associations between baseline functional test performances and depressive symptom trajectories were evaluated with univariable ordinal models. Subsequently, the adjusted cumulative odds ratio for the association between identified risk factors, demographic factors and baseline anti-depressant use were measured using multivariable ordinal logistic regression. RESULTS: Three distinct depressive symptom trajectories were identified: a low-and-stable course (10% of participants), a low-and-increasing course (81%) and a moderate-and-increasing course (9%). Timed Up and Go test time was the strongest risk factor of depressive symptom trajectory, followed by Five Times Sit-to-Stand test performance, planned physical activity levels, and knee extension strength (adjusted standardised ORs 1.65, 95% CI 1.34-2.04; 1.44, 95% CI 1.16-1.77; 1.44, 95% CI 1.17-1.76 and 1.41, 95% CI 1.15-1.73 respectively). After adjusting for age, sex, body mass index and baseline anti-depressant use, Timed Up and Go test performance and knee extension strength were independently and significantly associated with depressive trajectories. CONCLUSIONS: Timed Up and Go test times, Five Times Sit-to-Stand test performance, planned physical activity levels and knee extension strength are associated with three discrete depressive symptom trajectories. These clinical tests may help identify older adults aged 70-90 years at risk of developing depressive symptoms and help guide subsequent strength and mobility interventions.

Effect of a coaching intervention to enhance physical activity and prevent falls in community-dwelling people aged 60+ years: a cluster randomised controlled trial.

OBJECTIVES: To evaluate the effect of a coaching intervention compared with control on physical activity and falls rate at 12 months in community-dwelling people aged 60+ years. DESIGN: Cluster randomised controlled trial. SETTING: Community-dwelling older people. PARTICIPANTS: 72 clusters (605 participants): 37 clusters (290 participants) randomised to the intervention and 35 (315 participants) to control. INTERVENTION: Intervention group received written information, fall risk assessment and prevention advice by a physiotherapist, activity tracker and telephone-based coaching from a physiotherapist focused on safe physical activity. Control group received written information and telephone-based dietary coaching. Both groups received up to 19 sessions of telephone coaching over 12 months. OUTCOMES: The co-primary outcomes were device-measured physical activity expressed in counts per minute at 12 months and falls rate over 12 months. Secondary outcomes included the proportion of fallers, device-measured daily steps and moderate-to-vigorous physical activity (MVPA), self-reported hours per week of physical activity, body mass index, eating habits, goal attainment, mobility-related confidence, quality of life, fear of falling, risk-taking behaviour, mood, well-being and disability. RESULTS: The mean age of participants was 74 (SD 8) years, and 70% (n=425) were women. There was no significant effect of the intervention on device-measured physical activity counts per minute (mean difference 5 counts/min/day, 95% CI -21 to 31), or falls at 12 months (0.71 falls/person/year in intervention group and 0.87 falls/person/year in control group; incidence rate ratio 0.86, 95% CI 0.65 to 1.14). The intervention had a positive significant effect on device-measured daily steps and MVPA, and self-reported hours per week of walking, well-being, quality of life, and disability. No significant between-group differences were identified in other secondary outcomes. CONCLUSION: A physical activity and fall prevention programme including fall risk assessment and prevention advice, plus telephone-based health coaching, did not lead to significant differences in physical activity counts per minute or falls rate at 12 months. However, this programme improved other physical activity measures (ie, daily steps, MVPA, hours per week of walking), overall well-being, quality of life and disability. TRIAL REGISTRATION NUMBER: ACTRN12615001190594.

Exergame and cognitive training for preventing falls in community-dwelling older people: a randomized controlled trial.

Exergame training, in which video games are used to promote exercise, can be tailored to address cognitive and physical risk factors for falls and is a promising method for fall prevention in older people. Here, we performed a randomized clinical trial using the smart±step gaming system to examine the effectiveness of two home-based computer game interventions, seated cognitive training and step exergame training, for fall prevention in community-dwelling older people, as compared with a minimal-intervention control group. Participants aged 65 years or older (n = 769, 71% female) living independently in the community were randomized to one of three arms: (1) cognitive training using a computerized touchpad while seated, (2) exergame step training on a computerized mat or (3) control (provided with an education booklet on healthy ageing and fall prevention). The rate of falls reported monthly over 12 months-the primary outcome of the trial-was significantly reduced in the exergame training group compared with the control group (incidence rate ratio = 0.74, 95% confidence interval = 0.56-0.98), but was not statistically different between the cognitive training and control groups (incidence rate ratio = 0.86, 95% confidence interval = 0.65-1.12). No beneficial effects of the interventions were found for secondary outcomes of physical and cognitive function, and no serious intervention-related adverse events were reported. The results of this trial support the use of exergame step training for preventing falls in community-dwelling older people. As this intervention can be conducted at home and requires only minimal equipment, it has the potential for scalability as a public health intervention to address the increasing problem of falls and fall-related injuries. Australian and New Zealand Clinical Trial Registry identifier: ACTRN12616001325493 .

Cognitive and physical declines and falls in older people with and without mild cognitive impairment: a 7-year longitudinal study.

OBJECTIVES: We examined longitudinal changes in cognitive and physical function and associations between change in function and falls in people with and without mild cognitive impairment (MCI). DESIGN: Prospective cohort study with assessments every 2 years (for up to 6 years). SETTING: Community, Sydney, Australia. PARTICIPANTS: Four hundred and eighty one people were classified into three groups: those with MCI at baseline and MCI or dementia at follow-up assessments (n = 92); those who fluctuated between cognitively normal and MCI throughout follow-up (cognitively fluctuating) (n = 157), and those who were cognitively normal at baseline and all reassessments (n = 232). MEASUREMENTS: Cognitive and physical function measured over 2-6 years follow-up. Falls in the year following participants' final assessment. RESULTS: In summary, 27.4%, 38.5%, and 34.1% of participants completed 2, 4, and 6 years follow-up of cognitive and physical performance, respectively. The MCI and cognitive fluctuating groups demonstrated cognitive decline, whereas the cognitively normal group did not. The MCI group had worse physical function than the cognitively normal group at baseline but decline over time in physical performance was similar across all groups. Decline in global cognitive function and sensorimotor performance were associated with multiple falls in the cognitively normal group and decline in mobility (timed-up-and-go test) was associated with multiple falls across the whole sample. CONCLUSIONS: Cognitive declines were not associated with falls in people with MCI and fluctuating cognition. Declines in physical function were similar between groups and decline in mobility was associated with falls in the whole sample. As exercise has multiple health benefits including maintaining physical function, it should be recommended for all older people. Programs aimed at mitigating cognitive decline should be encouraged in people with MCI.

Is Maximal or Usual Walking Speed from Large Scale Wrist Sensor Data Better at Predicting Dementia, Depression and Death?

Older people are at increased risk of many adverse health outcomes, including dementia and depression, that burden the global health system. This paper presents algorithms for the large-scale assessment of daily walking speeds. We hypothesize that (i) data from wrist-worn sensors can be used to assess walking speed accurately; and that (ii) maximal daily walking speed is a better predictor of health outcomes than usual daily walking speed. First, algorithms were developed and tested using data from 101 participants aged 19 to 91 (47 ± 18) years. Participants wore an AX3 accelerometer (Axivity, UK) on their dominant wrist while undertaking daily life activities with electronic walkway data used for ground truth. Subsequently, prediction models for dementia, depression and death were developed using the data of 47,406 participants (≥ 60 years) from the UK Biobank study. Daily walking speeds were derived from 7-day AX3 data with time-to-events using electronic health records. The accuracy of derived walking speeds was assessed using root mean square error (RMSE). Time-to-events were modelled using Cox regression with inverse hazard ratios reported for univariable models and Harrell's concordance for multivariable models. Derived walking speeds had an RMSE of between 3% and 4% depending on arm position. We found that for simple models, maximal walking speed was significantly better than usual walking speed at predicting time to dementia (1.62 vs 1.34), depression (1.29 vs 1.17) and death (1.56 vs 1.27). However, the addition of known risk factors in subsequent multivariable models reduced the apparent benefit of using maximal as opposed to usual daily walking speed as the gait parameter. In summary, walking speed was accurately measured with a wrist-worn device, and maximal daily waking speed may be better than usual daily walking speed at predicting some adverse health outcomes.Clinical Relevance- This study demonstrated the validity of using a simple and unobtrusive wrist-worn sensor to remotely assess daily walking speed. As a single, modifiable and easily understood measure, maximal walking speed was shown to be better than usual walking speed at predicting time-to-dementia, depression and death. Therefore, the inclusion of maximal daily walking speed into screening programs and clinical interventions presents a promising area for further research.

Combined Reactive and Volitional Step Training Improves Balance Recovery and Stepping Reaction Time in People With Parkinson's Disease: A Randomised Controlled Trial.

BACKGROUND: Falls are frequent and devastating events for people with Parkinson's disease (PD). Here, we investigated whether laboratory-based reactive step training combined with home-based volitional step training was effective in improving balance recovery and stepping ability in people with PD. METHODS: Forty-four people with idiopathic PD were randomized into intervention or control groups. Intervention participants performed unsupervised volitional step training using home-based exergames (80+ minutes/week) for 12 weeks and attended reactive step training sessions in which they were exposed to slip and trip perturbations at 4 and 8 weeks. Control participants continued their usual activities. Primary outcomes were balance recovery following an induced-trip/slip and choice stepping reaction time (CSRT) at the 12-week reassessment. Secondary outcomes comprised sensorimotor, balance, cognitive, psychological, complex stepping (inhibitory CSRT and Stroop Stepping Test [SST]), gait measures, and falls experienced in everyday life. RESULTS: At reassessment, the intervention group had significantly fewer total laboratory-induced falls and faster CSRT compared to the control group (P < .05). The intervention group also had significantly faster inhibitory CSRT and SST movement times and made fewer mistakes in the SST (P < .05). There were no significant differences in the rate of every day falls or other secondary outcome measures between the groups. CONCLUSION: Combined volitional and reactive step training improved balance recovery from an induced-perturbation, voluntary stepping time, and stepping accuracy in cognitively challenging tests in people with PD. Further research is required to determine whether such combined step training can prevent daily-life falls in this population.

Prediction of injurious falls in older adults using digital gait biomarkers extracted from large-scale wrist sensor data.

OBJECTIVES: To determine whether digital gait biomarkers captured by a wrist-worn device can predict injurious falls in older people and to develop a multivariable injurious fall prediction model. DESIGN: Population-based longitudinal cohort study. SETTING AND PARTICIPANTS: Community-dwelling participants of the UK Biobank study aged 65 and older (n = 32,619) in the United Kingdom. METHODS: Participants were assessed at baseline on daily-life walking speed, quality, quantity and distribution using wrist-worn accelerometers for up to 7 days. Univariable and multivariable Cox proportional hazard regression models were used to analyse the associations between these parameters and injurious falls for up to 9 years. RESULTS: Five percent of the participants (n = 1,627) experienced at least one fall requiring medical attention over a mean of 7.0 ± 1.1 years. Daily-life walking speed, gait quality, quantity of walking and distribution of daily walking were all significantly associated with the incidence of injurious falls (P < 0.05). After adjusting for sociodemographics, lifestyle factors, comorbidities, handgrip strength and reaction time; running duration, total step counts and usual walking speed were identified as independent and significant predictors of falls (P < 0.01). These associations were consistent in those without a history of previous fall injuries. In contrast, step regularity was the only risk factor for those with a previous fall history after adjusting for covariates. CONCLUSIONS: Daily-life gait speed, quantity and quality, derived from wrist-worn sensors, are significant predictors of injurious falls in older people. These digital gait biomarkers could potentially be used to identify fall risk in screening programs and integrated into fall prevention strategies.

Associations between psychotropic and anti-dementia medication use and falls in community-dwelling older adults with cognitive impairment.

OBJECTIVES: Evidence for effective fall prevention strategies is limited for people with cognitive impairment. Understanding what factors contribute to fall risk identifies potential intervention strategies. We aimed to determine if psychotropic and anti-dementia medication use are associated with falls in community-dwelling older people with mild-moderate cognitive impairment and dementia. DESIGN: Secondary analysis of an RCT (i-FOCIS). PARTICIPANTS AND SETTING: 309 community-dwelling people with mild to moderate cognitive impairment or dementia from Sydney, Australia. METHODS: Demographic information, medical history, and medication use were collected at baseline and participants were followed up for 1-year for falls using monthly calendars and ancillary telephone falls. RESULTS: Psychotropic medication use was associated with an increased rate of falls (IRR 1.41, 95%CI 1.03, 1.93) and slower gait speed, poor balance and reduced lower limb function when adjusting for age, sex, education and cognition, as well as RCT group allocation when examining prospective falls. Antidepressants use increased the rate of falls in a similarly adjusted model (IRR 1.54, 95%CI 1.10, 2.15), but when additionally adjusting for depressive symptoms, antidepressant use was no longer significantly associated with falls while depressive symptoms was. Anti-dementia medication use was not associated with rate of falls. CONCLUSIONS: Psychotropic medication use increases fall risk, and anti-dementia medication does not reduce fall risk in older adults with cognitive impairment. Effective management of depressive symptoms, potentially with non-pharmacological approaches, is needed to prevent falls in this population. Research is also required to ascertain the risks/benefits of withdrawing psychotropic medications, particularly in relation to depressive symptoms.