Digital technologies to prevent falls in people living with dementia or mild cognitive impairment: a rapid systematic overview of systematic reviews.

OBJECTIVE: Falls are a common cause of potentially preventable death, disability and loss of independence with an annual estimated cost of £4.4bn. People living with dementia (PlwD) or mild cognitive impairment (MCI) have an increased fall risk. This overview evaluates evidence for technologies aiming to reduce falls and fall risk for PlwD or MCI. METHODS: In October 2022, we searched five databases for evidence syntheses. We used standard methods to rapidly screen, extract data, assess risk of bias and overlap, and synthesise the evidence for each technology type. RESULTS: We included seven systematic reviews, incorporating 22 relevant primary studies with 1,412 unique participants. All reviews had critical flaws on AMSTAR-2: constituent primary studies were small, heterogeneous, mostly non-randomised and assessed as low or moderate quality. Technologies assessed were: wearable sensors, environmental sensor-based systems, exergaming, virtual reality systems. We found no evidence relating to apps. Review evidence for the direct impact on falls was available only from environmental sensors, and this was inconclusive. For wearables and virtual reality technologies there was evidence that technologies may differentiate PlwD who fell from those who did not; and for exergaming that balance may be improved. CONCLUSIONS: The evidence for technology to reduce falls and falls risk for PlwD and MCI is methodologically weak, based on small numbers of participants and often indirect. There is a need for higher-quality RCTs to provide robust evidence for effectiveness of fall prevention technologies. Such technologies should be designed with input from users and consideration of the wider implementation context.

Effectiveness of dance interventions for falls prevention in older adults: systematic review and meta-analysis.

INTRODUCTION: Fall prevention is a global health priority. Strength and balance exercise programmes are effective at reducing falls. Emerging literature suggests dance is an enjoyable and sociable form of exercise. However, there is little evidence that dance reduces fall incidence. METHODS: Systematic review and meta-analysis examining effectiveness and cost-effectiveness of dance for falls prevention in older adults. Five databases were searched with no restrictions on publication date or intervention settings. Risk of bias was assessed using variants of Cochrane Risk of bias tools, Mixed-Methods Appraisal and Drummond checklist as appropriate. Certainty of evidence was assessed using GRADE. RESULTS: Forty-one studies were included (19 RCTs, 13 quasi-experimental, two mixed-method, seven observational studies, 2,451 participants). Five types of dance interventions were identified: ballroom and Latin dance, dance exercise, cultural dance, dance therapy, and low-impact dance. Meta-analysis was only possible for functional outcome measures: Timed-Up-and-Go (dance versus usual care, mean difference (MD) = 1.36; 95% CI -3.57 to 0.85), Sit-to-Stand (dance versus exercise MD = -0.85; 95% CI -2.64 to 0.93: dance versus education MD = -1.64; 95% CI -4.12 to 0.85), Berg Balance Scale (dance versus usual care MD = 0.61; 95% CI -4.26 to 5.47). There was unexplained variance in effects and no significant differences between intervention and control groups. Overall, certainty of evidence was very low; we are uncertain about the effect of dance interventions in reducing falls. CONCLUSIONS: There is very low certainty evidence for dance as an alternative to strength and balance training if the aim is to prevent falls. No robust evidence on the cost-effectiveness of dance interventions for the prevention of falls was found. PROSPERO REGISTRATION: CRD42022382908.

Population-based interventions for preventing falls and fall-related injuries in older people.

BACKGROUND: Around one-third of older adults aged 65 years or older who live in the community fall each year. Interventions to prevent falls can be designed to target the whole community, rather than selected individuals. These population-level interventions may be facilitated by different healthcare, social care, and community-level agencies. They aim to tackle the determinants that lead to risk of falling in older people, and include components such as community-wide polices for vitamin D supplementation for older adults, reducing fall hazards in the community or people's homes, or providing public health information or implementation of public health programmes that reduce fall risk (e.g. low-cost or free gym membership for older adults to encourage increased physical activity). OBJECTIVES: To review and synthesise the current evidence on the effects of population-based interventions for preventing falls and fall-related injuries in older people. We defined population-based interventions as community-wide initiatives to change the underlying societal, cultural, or environmental conditions increasing the risk of falling. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in December 2020, and conducted a top-up search of CENTRAL, MEDLINE, and Embase in January 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster RCTs, trials with stepped-wedge designs, and controlled non-randomised studies evaluating population-level interventions for preventing falls and fall-related injuries in adults ≥ 60 years of age. Population-based interventions target entire communities. We excluded studies only targeting people at high risk of falling or with specific comorbidities, or residents living in institutionalised settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane, and used GRADE to assess the certainty of the evidence. We prioritised seven outcomes: rate of falls, number of fallers, number of people experiencing one or more fall-related injuries, number of people experiencing one or more fall-related fracture, number of people requiring hospital admission for one or more falls, adverse events, and economic analysis of interventions. Other outcomes of interest were: number of people experiencing one or more falls requiring medical attention, health-related quality of life, fall-related mortality, and concerns about falling. MAIN RESULTS: We included nine studies: two cluster RCTs and seven non-randomised trials (of which five were controlled before-and-after studies (CBAs), and two were controlled interrupted time series (CITS)). The numbers of older adults in intervention and control regions ranged from 1200 to 137,000 older residents in seven studies. The other two studies reported only total population size rather than numbers of older adults (67,300 and 172,500 residents). Most studies used hospital record systems to collect outcome data, but three only used questionnaire data in a random sample of residents; one study used both methods of data collection. The studies lasted between 14 months and eight years. We used Prevention of Falls Network Europe (ProFaNE) taxonomy to classify the types of interventions. All studies evaluated multicomponent falls prevention interventions. One study (n = 4542) also included a medication and nutrition intervention. We did not pool data owing to lack of consistency in study designs. Medication or nutrition Older people in the intervention area were offered free-of-charge daily supplements of calcium carbonate and vitamin D3. Although female residents exposed to this falls prevention programme had fewer fall-related hospital admissions (with no evidence of a difference for male residents) compared to a control area, we were unsure of this finding because the certainty of evidence was very low. This cluster RCT included high and unclear risks of bias in several domains, and we could not determine levels of imprecision in the effect estimate reported by study authors. Because this evidence is of very low certainty, we have not included quantitative results here. This study reported none of our other review outcomes. Multicomponent interventions Types of interventions included components of exercise, environment modification (home; community; public spaces), staff training, and knowledge and education. Studies included some or all of these components in their programme design. The effectiveness of multicomponent falls prevention interventions for all reported outcomes is uncertain. The two cluster RCTs included high or unclear risk of bias, and we had no reasons to upgrade the certainty of evidence from the non-randomised trial designs (which started as low-certainty evidence). We also noted possible imprecision in some effect estimates and inconsistent findings between studies. Given the very low-certainty evidence for all outcomes, we have not reported quantitative findings here. One cluster RCT reported lower rates of falls in the intervention area than the control area, with fewer people in the intervention area having one or more falls and fall-related injuries, but with little or no difference in the number of people having one or more fall-related fractures. In another cluster RCT (a multi-arm study), study authors reported no evidence of a difference in the number of female or male residents with falls leading to hospital admission after either a multicomponent intervention ("environmental and health programme") or a combination of this programme and the calcium and vitamin D3 programme (above). One CBA reported no difference in rate of falls between intervention and control group areas, and another CBA reported no difference in rate of falls inside or outside the home. Two CBAs found no evidence of a difference in the number of fallers, and another CBA found no evidence of a difference in fall-related injuries. One CITS found no evidence of a difference in the number of people having one or more fall-related fractures. No studies reported adverse events. AUTHORS' CONCLUSIONS: Given the very low-certainty evidence, we are unsure whether population-based multicomponent or nutrition and medication interventions are effective at reducing falls and fall-related injuries in older adults. Methodologically robust cluster RCTs with sufficiently large communities and numbers of clusters are needed. Establishing a rate of sampling for population-based studies would help in determining the size of communities to include. Interventions should be described in detail to allow investigation of effectiveness of individual components of multicomponent interventions; using the ProFaNE taxonomy for this would improve consistency between studies.

Association of two geriatric treatment systems with anti-osteoporotic drug treatment and second hip fracture in patients with an index hip fracture: retrospective cohort study.

BACKGROUND: In Germany, geriatricians deliver acute geriatric care during acute hospital stay and post-acute rehabilitation after transfer to a rehabilitation clinic. The rate patients receive acute geriatric care (AGC) or are transferred to post-acute rehabilitation (TPR) differs between hospitals. This study analyses the association between the two geriatric treatment systems (AGC, TPR) and second hip fracture in patients following an index hip fracture. METHODS: Nationwide health insurance data are used to identify the rate of AGC and TPR per hospital following hip fracture surgery in patients aged ≥ 80 years. Outcomes are a second hip fracture after surgery or after discharge within 180 or 360 days and new specific anti-osteoporotic drugs. Cox proportional hazard models and generalised linear models are applied. RESULTS: Data from 29,096 hip fracture patients from 652 hospitals were analysed. AGC and TPR are not associated with second hip fracture when follow-up started after surgery. However, during the first months after discharge patients from hospitals with no AGC or low rates of TPR have higher rates of second hip fracture than patients from hospitals with high rates of AGC or high rates of TPR (Hazard Ratio (95% CI) 1.35 (1.01-1.80) or 1.35 (1.03-1.79), respectively). Lower rates of AGC are associated with lower probabilities of new prescriptions of specific anti-osteoporotic drugs. CONCLUSIONS: Our study suggests beneficial relationships of geriatric treatment after hip fracture with a) the risk of second hip fractures during the first months after discharge and b) an improvement of anti-osteoporotic drug treatment.

Food intolerance related to gastrointestinal symptoms amongst adults living with bile acid diarrhoea: A cross-sectional study.

BACKGROUND: The role of food in managing bile acid diarrhoea (BAD) is poorly understood. The present study explored the prevalence of food intolerance amongst adults with BAD. METHODS: The study comprised a cross-sectional survey of adults with BAD determined by the 75 selenium homotaurocholic acid test (SeHCAT) living in the UK. Participants anonymously completed an online questionnaire on 39 food items. Frequency of food in general affecting BAD symptoms, as well as frequencies of diarrhoea, abdominal pain, bloating, flatulence and consequential food avoidance after food item ingestion, were assessed. Food group avoidance was also assessed. RESULTS: There were 434 participants who completed the questionnaire between April and May 2021 of whom 80% reported moderate to severe chronic diarrhoea. Food intolerances were reported by 88.0% (95% confidence interval [CI] = 84.6-90.9) of participants. Diarrhoea was reported most frequently after take-away food, fish and chips, creamy sauces, cream and large quantities of fruit (range 41.0%-33.6%). Lowest frequencies were for potato, avocado, mango, watermelon and pear (range 3.7%-7.4%) for the foods listed in the questionnaire. Similar trends were found for abdominal pain, bloating, flatulence and consequential food avoidance. Symptom-triggering within 30 min of ingestion was more prevalence than after 30 min for almost all foods. Food group avoidance was highest for fatty foods (81.2%; 95% CI = 77.8-85.3) followed by dairy (53.9%; 95% CI = 49.1-58.7). CONCLUSIONS: Perceived food intolerance amongst adults with BAD and persisting diarrhoeal symptoms is high. Important triggers were meals with a higher fat content and higher-fat dairy products. Diets amongst those with persisting diarrhoeal symptoms may be overly restrictive.

Interactions that support older inpatients with cognitive impairments to engage with falls prevention in hospitals: An ethnographic study.

AIMS: To explore the nature of interactions that enable older inpatients with cognitive impairments to engage with hospital staff on falls prevention. DESIGN: Ethnographic study. METHODS: Ethnographic observations on orthopaedic and older person wards in English hospitals (251.25 h) and semi-structured qualitative interviews with 50 staff, 28 patients and three carers. Findings were analysed using a framework approach. RESULTS: Interactions were often informal and personalised. Staff qualities that supported engagement in falls prevention included the ability to empathise and negotiate, taking patient perspectives into account. Although registered nurses had limited time for this, families/carers and other staff, including engagement workers, did so and passed information to nurses. CONCLUSIONS: Some older inpatients with cognitive impairments engaged with staff on falls prevention. Engagement enabled them to express their needs and collaborate, to an extent, on falls prevention activities. To support this, we recommend wider adoption in hospitals of engagement workers and developing the relational skills that underpin engagement in training programmes for patient-facing staff. IMPLICATIONS FOR PROFESSION AND PATIENT CARE: Interactions that support cognitively impaired inpatients to engage in falls prevention can involve not only nurses, but also families/carers and non-nursing staff, with potential to reduce pressures on busy nurses and improve patient safety. REPORTING METHOD: The paper adheres to EQUATOR guidelines, Standards for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: Patient/public contributors were involved in study design, evaluation and data analysis. They co-authored this manuscript.

Interventions Based on Behavior Change Techniques to Encourage Physical Activity or Decrease Sedentary Behavior in Community-Dwelling Adults Aged 50-70: Systematic Review With Intervention Component Analysis.

Increasing physical activity (PA) and/or decreasing sedentary behaviors is important in the delay and prevention of long-term conditions. PA can help maintain function and independence and decrease the need for hospitalization/institutionalization. Activity rates often decline in later life resulting in a need for interventions that encourage uptake and adherence through the use of Behavior Change Techniques (BCTs). We conducted a systematic review of the evidence for interventions that included BCTs in community-dwelling adults with a mean age of 50-70. The review followed PRISMA guidelines. The interventions were psychosocial, nonpharmacological, and noninvasive interventions utilizing components based on BCTs that evaluated change in PA and/or sedentary behavior. Intervention Component Analysis (ICA) was used to synthesize effectiveness of intervention components. Twelve randomized controlled trials were included in this review. The mean sample age was 50-64. Thirteen BCTs were used across all studies, and the most commonly used techniques were goals and planning, feedback and monitoring, and natural consequences. Seven intervention components linked with BCTs were found: personalized goal setting, tailored feedback from facilitators, on-site and postintervention support, education materials and resources, reinforcing change on behavior and attitudes, self-reported monitoring, and social connectedness. All components, except for social connectedness, were associated with improved health behavior and PA levels. The interventions that use BCTs have incorporated strategies that reinforce change in behavior and attitudes toward PA.

A systematic review and meta-analysis of the measurement properties of concerns-about-falling instruments in older people and people at increased risk of falls.

BACKGROUND: The 16-item Falls Efficacy Scale International (FES-I) is widely used to assess concerns-about-falling. Variants include 7-item Short FES-I, 30-item Iconographical Falls Efficacy Scale (Icon FES) and 10-item short Icon FES. No comprehensive systematic review and meta-analysis has been conducted to synthesise evidence regarding the measurement properties of these tools. OBJECTIVES: To conduct a systematic review and meta-analysis of the measurement properties of four FES-I variants. METHODS: MEDLINE, Embase, CINAHL Plus, PsycINFO and Web of Science were searched systematically and articles were assessed for eligibility independently. The methodological quality of eligible studies was assessed using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. The quality of measurement properties was assessed using COSMIN criteria for good measurement properties. Where possible, meta-analysis was conducted; otherwise, narrative synthesis was performed. Overall certainty of evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation system approach. RESULTS: The review included 58 studies investigating measurement properties of the four instruments. There was high-quality evidence to support internal consistency, reliability and construct validity of all instruments. Moderate- to high-certainty evidence suggests one-factor structure of FES-I with two underlying dimensions, one-factor structure of Short FES-I and two-factor structure of Icon FES. There was high-certainty evidence to support the responsiveness of FES-I, with further research needed for the other instruments. CONCLUSION: There is evidence for excellent measurement properties of all four instruments. We recommend the use of these tools with healthy older people and people at a greater risk of falls due to conditions that might affect mobility and balance.

A prospective analysis examining frailty remission and the association with future falls risk in older adults in England.

BACKGROUND: Previous research has shown older adults experience dynamic changes in frailty status. This study aimed to determine the occurrence of sustained frailty remission and how remission is associated with falls risk. METHODS: Participants who contributed data to the analysis were in the English Longitudinal Study of Ageing from Waves 1 to 8 (2002-2017). Frailty was defined across waves using the frailty index and categorised into robust, pre-frail and frail. We classified participants who improved their frailty category from Wave 1 (2002) to Wave 2 (2004) and sustained/improved category again into Wave 3 (2006) and compared them with those who were either robust or frail across Waves 1-3. Cox proportional hazard modelling was used to determine the risk of incident falls reported at Waves 4-8, with results expressed as hazard ratios and 95% confidence intervals. RESULTS: Of 2,564 participants, 389 (15·2%) improved frailty category and sustained this during Waves 2-3, 1,489 (58·1%) remained robust and 686 (26·8%) remained frail during Waves 1-3. During the 10-year period (Waves 4-8), a total of 549 participants reported a fall. Compared with those who remained frail during Waves 1-3, those who with sustained frailty remission had a lower risk of future falls (HR 0·41; 95% CI = 0·36-0·45). CONCLUSIONS: Frailty remission is possible and can be sustained across 5 years. There is a lower risk of future falls in those who sustain frailty remission compared with those who remain frail.

'That's as hard a decision as you will ever have to make': the experiences of people who discussed Do Not Attempt Cardiopulmonary Resuscitation on behalf of a relative during the COVID-19 pandemic.

BACKGROUND: COVID-19 brought additional challenges to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision-making, which was already a contentious issue. In the UK, reports of poor DNACPR decision-making and communication emerged in 2020, including from the regulator, the Care Quality Commission. This paper explores the experiences of people who discussed DNACPR with a healthcare professional on behalf of a relative during the coronavirus pandemic, with the aim of identifying areas of good practice and what needs to be improved. METHODS: a total of 39 people participated in semi-structured interviews via video conferencing software or telephone. Data were evaluated using Framework Analysis. FINDINGS: results are presented around three main themes: understanding, communication and impact. Participants' understanding about DNACPR was important, as those with better understanding tended to reflect more positively on their discussions with clinicians. The role of relatives in the decision-making process was a frequent source of misunderstanding. Healthcare professionals' communication skills were important. Where discussions went well, relatives were given clear explanations and the opportunity to ask questions. However many relatives felt that conversations were rushed. DNACPR discussions can have a lasting impact-relatives reported them to be significant moments in care journeys. Many relatives perceived that they were asked to decide whether their relative should receive CPR and described enduring emotional consequences, including guilt. CONCLUSION: the pandemic has illuminated deficiencies in current practice around DNACPR discussion, which can have difficult to anticipate and lasting negative consequences for relatives. This research raises questions about the current approach to DNACPR decision-making.

Why should clinical practitioners ask about their patients' concerns about falling?

Concerns (or 'fears') about falling (CaF) are common in older adults. As part of the 'World Falls Guidelines Working Group on Concerns about Falling', we recommended that clinicians working in falls prevention services should regularly assess CaF. Here, we expand upon these recommendations and argue that CaF can be both 'adaptive' and 'maladaptive' with respect to falls risk. On the one hand, high CaF can lead to overly cautious or hypervigilant behaviours that increase the risk of falling, and may also cause undue activity restriction ('maladaptive CaF'). But concerns can also encourage individuals to make appropriate modifications to their behaviour to maximise safety ('adaptive CaF'). We discuss this paradox and argue that high CaF-irrespective of whether 'adaptive' or 'maladaptive'-should be considered an indication that 'something is not right', and that is represents an opportunity for clinical engagement. We also highlight how CaF can be maladaptive in terms of inappropriately high confidence about one's balance. We present different routes for clinical intervention based on the types of concerns disclosed.

Household wealth, neighbourhood deprivation and frailty amongst middle-aged and older adults in England: a longitudinal analysis over 15 years (2002-2017).

BACKGROUND: frailty is a condition of reduced function and health due to ageing processes and is associated with a higher risk of falls, hospitalisation, disability and mortality. OBJECTIVE: to determine the relationship between household wealth and neighbourhood deprivation with frailty status, independently of demographic factors, educational attainment and health behaviours. DESIGN: population-based cohort study. SETTING: communities in England. SUBJECTS: in total 17,438 adults aged 50+ from the English Longitudinal Study of Ageing. METHODS: multilevel mixed-effects ordered logistic regression was used in this study. Frailty was measured using a frailty index. We defined small geographic areas (neighbourhoods) using English Lower layer Super Output Areas. Neighbourhood deprivation was measured by the English Index of Multiple Deprivation, grouped into quintiles. Health behaviours included in this study are smoking and frequency of alcohol consumption. RESULTS: the proportion of respondents who were prefrail and frail were 33.8% [95% confidence interval (CI) 33.0-34.6%] and 11.7 (11.1-12.2)%, respectively. Participants in the lowest wealth quintile and living in the most deprived neighbourhood quintile had 1.3 (95% CI = 1.2-1.3) and 2.2 (95% CI = 2.1-2.4) times higher odds of being prefrail and frail, respectively, than the wealthiest participants living in the least deprived neighbourhoods Living in more deprived neighbourhood and poorer wealth was associated with an increased risk of becoming frail. Those inequalities did not change over time. CONCLUSIONS: in this population-based sample, living in a deprived area or having low wealth was associated with frailty in middle-aged and older adults. This relationship was independent of the effects of individual demographic characteristics and health behaviours.

Comparison of falls and cost-effectiveness of the group versus individually delivered Lifestyle-integrated Functional Exercise (LiFE) program: final results from the LiFE-is-LiFE non-inferiority trial.

BACKGROUND: the individually delivered Lifestyle-integrated Functional Exercise (LiFE) was shown to improve physical activity (PA) and reduce fall incidence, however being rather resource-consuming due to one-to-one delivery. A potentially less resource-intensive group format (gLiFE) was developed and compared against the original program, considering higher risk of falling due to possible PA enhancement. OBJECTIVE: to investigate non-inferiority in terms of PA-adjusted fall risk and cost-effectiveness of gLiFE at 12-month follow-up. DESIGN: single-blinded, randomised, multi-centre non-inferiority trial. SETTING: community. SUBJECTS: in total, 309 adults aged 70+ years at risk of or with history of falling; n = 153 in gLiFE, n = 156 in LiFE. METHODS: LiFE was delivered one-to-one at the participants' homes, gLiFE in a group. PA-adjusted fall risk was analysed using negative binomial regression to compare incidence rate ratios (IRR). Cost-effectiveness was presented by incremental cost-effectiveness ratios and cost-effectiveness acceptability curves, considering quality-adjusted life years, PA and falls as effect measures. Secondary analyses included PA (steps/day) and fall outcomes. RESULTS: non-inferiority was inconclusive (IRR 0.96; 95% confidence interval, CI 0.67; 1.37); intervention costs were lower for gLiFE, but cost-effectiveness was uncertain. gLiFE participants significantly increased PA (+1,090 steps/day; 95% CI 345 and 1.835) versus insignificant increase in LiFE (+569, 95% CI -31; 1,168). Number of falls and fallers were reduced in both formats. CONCLUSION: non-inferiority of gLiFE compared with LiFE was inconclusive after 12 months. Increases in PA were clinically relevant in both groups, although nearly twice as high in gLiFE. Despite lower intervention costs of gLiFE, it was not clearly superior in terms of cost-effectiveness.

Unrepresented, unheard and discriminated against: A qualitative exploration of relatives' and professionals' views of palliative care experiences of people of African and Caribbean descent during the COVID-19 pandemic.

BACKGROUND: People of African and Caribbean descent experienced disproportionately high mortality from COVID-19 and have poor access to palliative care. AIM: To explore palliative care experiences of people of African and Caribbean descent during and immediately prior to the pandemic. DESIGN: Qualitative interview study with thematic analysis. Refinement of themes/recommendations in consultation with an expert patient and public advisory group. SETTING/PARTICIPANTS: Twenty-six bereaved relatives and 13 health/social care professionals (cared for people of African and Caribbean descent) from throughout England, recruited using social media, community networks and direct advertising to over 150 organisations. RESULTS: Three themes were identified: Representation: Participants did not see themselves reflected in the palliative care services and did not expect their needs to be understood. Mistrust of the healthcare system and perceptions of racism were common and led to anticipation of inequitable care. Personalisation: Relatives and professionals reported a lack of cultural and religious sensitivity in healthcare. Assumptions were made based on ethnicity, and services not offered to all. Awareness and education: Professionals felt they lacked the knowledge to provide care to diverse communities, but were reluctant to ask, due to fear of making mistakes. Inequitable access to services was exacerbated by, but not unique to, the pandemic. Participants recommended raising awareness of palliative services, building professional competence in culturally-sensitive care, and greater ethnic diversity within services. CONCLUSIONS: Person-centred, culturally-competent palliative care is not the norm for people of African and Caribbean descent. Expectations of inequitable care are widespread. Sustained action on multiple fronts is needed.

Using Smartphone TechnolOGy to Support an EffecTive Home ExeRcise Intervention to Prevent Falls amongst Community-Dwelling Older Adults: The TOGETHER Feasibility RCT.

INTRODUCTION: Falls have major implications for quality of life, independence, and cost of health services. Strength and balance training has been found to be effective in reducing the rate/risk of falls, as long as there is adequate fidelity to the evidence-based programme. The aims of this study were to (1) assess the feasibility of using the "Motivate Me" and "My Activity Programme" interventions to support falls rehabilitation when delivered in practice and (2) assess study design and trial procedures for the evaluation of the intervention. METHODS: A two-arm pragmatic feasibility randomized controlled trial was conducted with five health service providers in the UK. Patients aged 50+ years eligible for a falls rehabilitation exercise programme from community services were recruited and received either (1) standard service with a smartphone for outcome measurement only or (2) standard service plus the "Motivate Me" and "My Activity Programme" apps. The primary outcome was feasibility of the intervention, study design, and procedures (including recruitment rate, adherence, and dropout). Outcome measures include balance, function, falls, strength, fear of falling, health-related quality of life, resource use, and adherence, measured at baseline, three-month, and six-month post-randomization. Blinded assessors collected the outcome measures. RESULTS: Twenty four patients were randomized to control group and 26 to intervention group, with a mean age of 77.6 (range 62-92) years. We recruited 37.5% of eligible participants across the five clinical sites. 77% in the intervention group completed their full exercise programme (including the use of the app). Response rates for outcome measures at 6 months were 77-80% across outcome measures, but this was affected by the COVID-19 pandemic. There was a mean 2.6 ± 1.9 point difference between groups in change in Berg balance score from baseline to 3 months and mean 4.4 ± 2.7 point difference from baseline to 6 months in favour of the intervention group. Less falls (1.8 ± 2.8 vs. 9.1 ± 32.6) and less injurious falls (0.1 ± 0.5 vs. 0.4 ± 0.6) in the intervention group and higher adherence scores at three (17.7 ± 6.8 vs. 13.1 ± 6.5) and 6 months (15.2 ± 7.8 vs. 14.9 ± 6.1). There were no related adverse events. Health professionals and patients had few technical issues with the apps. CONCLUSIONS: The motivational apps and trial procedures were feasible for health professionals and patients. There are positive indications from outcome measures in the feasibility trial, and key criteria for progression to full trial were met.

Acceptability of physical activity signposting for pre-frail older adults: a qualitative study to inform intervention development.

Frailty is a medical condition common in older adults characterised by diminished strength and reduced physiologic function in which individuals are more vulnerable to multiple adverse health outcomes. Pre-frailty is an intermediate stage associated with some minor health outcomes. However, the main risk is progression toward moderate/severe frailty. Evidence shows physical activity interventions to be effective in slowing or modifying the progression of frailty. Researchers at the University of Manchester are developing a behaviour change intervention targeting pre-frail older adults, signposting them to group-based physical activity classes known to be effective for delaying/slowing frailty. This paper reports on the initial intervention development work with key stakeholders exploring the practicality of taking forward this intervention and identifying uncertainties to be explored in the feasibility stage. These included issues around physical activity messaging, the use of the term 'frail', identification/recruitment of pre-frail older adults, and the acceptability of behaviour change techniques. There was overwhelming support for a proactive approach to addressing pre-frailty issues. Given that a large proportion of older adults are estimated to be pre-frail, interventions aimed at this group have the potential to support healthy ageing, positively impacting on frailty outcomes and providing wider population health benefits.

Exercise instructors are not consistently implementing the strength component of the UK chief medical officers' physical activity guidelines in their exercise prescription for older adults.

Strength training recommendations have been embedded within the UK's Chief Medical Officers' physical activity guidelines since 2011. There is limited evidence that these recommendations are used by exercise instructors in the community to underpin strength training prescription in the older adult population. This study aimed to explore exercise instructors' awareness and utilisation of the guidelines when prescribing strength training to older adults. Fifteen exercise instructors working with older adults in the UK participated in one online interview. A general inductive approach was conducted and thematic analysis allowed for major themes to be identified from the raw data. We found that most exercise instructors (n = 9), but not all (n = 6), were aware of the guidelines. Only one instructor (n = 1) had reportedly implemented the guidelines into their practice; other instructors reported that the guidelines were irrelevant. Instead, each of the instructors had their preferred sources of information that they relied on to underpin their exercise prescription, and each had their own interpretation of 'evidence-based strength training.' This individualised interpretation resulted in exceptionally varied prescription in the community and does not necessarily align with the progressive, evidence-based prescription known to build muscular strength. We suggest that (i) more detail on how to build muscular strength be embedded within the guidelines, (ii) a handbook on how to implement the guidelines be made available, (iii) theoretical and practical teaching materials and courses be updated, and/or (iv) a re-(education) of exercise instructors already in the field may be necessary to bring about a consistent, evidence-based strength prescription necessary for the best possible health and longevity outcomes for our ageing population.

What matters to people with multiple long-term conditions and their carers?

BACKGROUND: The number of people living with multiple long-term conditions is increasing worldwide. This presents challenges for health and care systems, which must adapt to meet the needs of this population. This study drew on existing data to understand what matters to people living with multiple long-term conditions and identify priorities for future research. METHODS: Two studies were conducted. (1) A secondary thematic analysis of interview, survey and workshop data collected from the 2017 James Lind Alliance Priority Setting Partnership for Older People with Multiple Conditions, and patient and public involvement workshops; (2) a review of ongoing research and published research priorities, relating to older people (80+) living with multiple long-term conditions. FINDINGS: Older people with multiple long-term conditions identified a number of key concerns: access to care, support for both the patient and their carer, physical and mental health and well-being and identifying opportunities for early prevention. The review identified no published research priorities or ongoing research focusing specifically on populations aged over 80 years with multiple long-term conditions. CONCLUSION: Older people living with multiple long-term conditions experience care that is inadequate for their needs. A holistic approach to care that extends beyond treating single conditions will ensure wide-ranging needs are met. As multimorbidity rises worldwide, this is a critical message for practitioners across health and care settings. We also recommend key areas that should be given greater focus in future research and policy to inform effective and meaningful forms of support for people living with multiple long-term conditions.

Adherence to mHealth and Paper-Based Versions of Lifestyle-Integrated Functional Exercise: A Secondary Analysis of Data From the PreventIT Feasibility Randomized Controlled Trial.

The European Commission Horizon 2020 project-PreventIT-evaluated two approaches to delivering Lifestyle-Integrated Functional Exercise (LiFE) programs for maintaining older adults' physical function: the paper-based adapted LiFE and mobile health device delivered enhanced LiFE. A self-reported method was used to measure users' monthly adherence over 12 months. This analysis aimed to explore young seniors' adherence patterns between enhanced LiFE and adapted LiFE groups. Results showed that adherence level decreased with time in both groups. The enhanced LiFE group had slightly higher adherence than the adapted LiFE group during most of the 12 months. However, the overall adherence levels were not significantly different during either intervention or follow-up periods. Monthly self-reported adherence measurement can help to understand users' adherence comprehensively. The comparable adherence levels between both groups indicate mobile health could be an alternative to delivering home-based physical activity for young seniors. However, this feasibility study was not powered to detect differences between groups.

A systematic literature review and meta-analysis on digital health interventions for people living with dementia and Mild Cognitive Impairment.

OBJECTIVES: Digital health interventions enable services to support people living with dementia and Mild Cognitive Impairment (MCI) remotely. This literature review gathers evidence on the effectiveness of digital health interventions on physical, cognitive, behavioural and psychological outcomes, and Activities of Daily Living in people living with dementia and MCI. METHODS/DESIGN: Searches, using nine databases, were run in November 2021. Two authors carried out study selection/appraisal using the Critical Appraisal Skills Programme checklist. Study characteristics were extracted through the Cochrane handbook for systematic reviews of interventions data extraction form. Data on digital health interventions were extracted through the template for intervention description and replication (TIDieR) checklist and guide. Intervention effectiveness was determined through effect sizes. Meta-analyses were performed to pool data on intervention effectiveness. RESULTS: Twenty studies were included in the review, with a diverse range of interventions, modes of delivery, activities, duration, length, frequency, and intensity. Compared to controls, the interventions produced a moderate effect on cognitive abilities (SMD = 0.36; 95% CI = -0.03 to 0.76; I2  = 61%), and a negative moderate effect on basic ADLs (SMD = -0.40; 95% CI = -0.86 to 0.05; I2  = 69%). Stepping exergames generated the largest effect sizes on physical and cognitive abilities. Supervised training produced larger effect sizes than unsupervised interventions. CONCLUSION: Supervised intervention delivery is linked to greatest benefits. A mix of remote and face-to-face delivery could maximise benefits and optimise costs. Accessibility, acceptability and sustainability of digital interventions for end-users must be pre-requisites for the development of future successful services.