"Now I Am Walking Toward Health": A Qualitative Study About the Outcomes of Physical Activity Participation That Matter to Older Adults.

BACKGROUND/OBJECTIVES: Randomized controlled trials that deliver physical activity interventions have demonstrated benefits for older adults across numerous health outcomes. However, too little attention has been directed to ensuring that such trials are measuring patient-relevant outcomes. To support outcome selection for future trials, the objective of this study was to understand what outcomes related to their physical activity participation older adults find important. METHODS: We conducted 12 semistructured interviews with adults aged 65 years and older and analyzed interview transcripts with a reflexive thematic analysis. RESULTS: Older adults desired diverse outcomes from their physical activity participation, ranging from generic (e.g., quality of life) to specific (e.g., leg strength). Relevant outcomes were classified under five themes: physical, clinical, social, psychological, and overarching, each with respective subthemes. CONCLUSIONS: The outcomes that older adults found important were plentiful and rooted in a desire to improve their quality of life. Some of the outcome themes have been reported frequently in past trials (e.g., physical), but others have not (e.g., social). Future researchers should be aware of, and responsive to, the priorities of older adults when designing trials and defining outcomes. Significance/Implications: This study will help to improve outcome selection for future trials of physical activity with older adults. In alignment with a patient-oriented research philosophy, this study will also ground future outcome selection in the priorities of older adults.

Outcome domains measured in randomized controlled trials of physical activity for older adults: a rapid review.

BACKGROUND: Toward development of a core outcome set for randomized controlled trials (RCTs) of physical activity (PA) interventions for older adults, the purpose of this study was to identify outcome domains and subdomains ('what' was measured) in previously published RCTs of PA for older adults. METHODS: We conducted a rapid review and searched Ovid MEDLINE for recently- published (2015-2021), English-language, RCTs of PA interventions for older adults (mean age 60+ yrs). We limited to articles published in Web of Science top-10 journals in general and internal medicine, geriatrics and gerontology, rehabilitation, and sports science. Two reviewers independently completed eligibility screening; two other reviewers abstracted trial descriptors and study outcomes. We classified study outcomes according to the standard outcome classification taxonomy endorsed by the Core Outcome Measures in Effectiveness Trials Initiative. RESULTS: Our search yielded 548 articles; 67 articles were eligible to be included. Of these, 82% were efficacy/effectiveness trials, 85% included both male and female participants, and 84% recruited community-dwelling older adults. Forty percent of articles reported on interventions that involved a combination of group and individual PAs, and 60% involved a combination of PA modes (e.g., aerobic, resistance). Trial sample size ranged from 14 to 2157 participants, with median (IQR) of 94 (57-517); 28,649 participants were included across all trials. We identified 21 unique outcome domains, spanning 4/5 possible core areas (physiological/clinical; life impact; resource use; adverse events). The five most commonly reported outcome domains were physical functioning (included in n=51 articles), musculoskeletal and connective tissue (n=30), general (n=26), cognitive functioning (n=16), and emotional functioning/wellbeing (n=14). Under these five outcome domains, we further identified 10 unique outcome subdomains (e.g., fall-related; body composition; quality of life). No outcome domains or subdomains were reported consistently in all RCTs. CONCLUSIONS: We found extensive variability in outcome domains and subdomains used in RCTs of PA for older adults, reflecting the broad range of potential health benefits derived from PA and also investigator interest to monitor a range of safety parameters related to adverse events. This study will inform development of a core outcome set to improve outcome reporting consistency and evidence quality.

Protective responses of older adults for avoiding injury during falls: evidence from video capture of real-life falls in long-term care.

BACKGROUND: falls are common in older adults, and any fall from standing height onto a rigid surface has the potential to cause a serious brain injury or bone fracture. Safe strategies for falling in humans have traditionally been difficult to study. OBJECTIVE: to determine whether specific 'safe landing' strategies (body rotation during descent, and upper limb bracing) separate injurious and non-injurious falls in seniors. DESIGN: observational cohort study. SETTING: two long-term care homes in Vancouver BC. METHODS: videos of 2,388 falls experienced by 658 participants (mean age 84.0 years; SD 8.1) were analysed with a structured questionnaire. General estimating equations were used to examine how safe landing strategies associated with documented injuries. RESULTS: injuries occurred in 38% of falls, and 4% of falls caused injuries treated in hospitals. 32% of injuries were to the head. Rotation during descent was common and protective against injury. In 43% of falls initially directed forward, participants rotated to land sideways, which reduced their odds for head injury 2-fold. Upper limb bracing was used in 58% of falls, but rather than protective, bracing was associated with an increased odds for injury, possibly because it occurred more often in the demanding scenario of forward landings. CONCLUSIONS: the risk for injury during falls in long-term care was reduced by rotation during descent, but not by upper limb bracing. Our results expand our understanding of human postural responses to falls, and point towards novel strategies to prevent fall-related injuries.

The SAFEST review: a mixed methods systematic review of shock-absorbing flooring for fall-related injury prevention.

BACKGROUND: Shock-absorbing flooring may minimise impact forces incurred from falls to reduce fall-related injuries; however, synthesized evidence is required to inform decision-making in hospitals and care homes. METHODS: This is a Health Technology Assessment mixed methods systematic review of flooring interventions targeting older adults and staff in care settings. Our search incorporated the findings from a previous scoping review, MEDLINE, AgeLine, and Scopus (to September 2019) and other sources. Two independent reviewers selected, assessed, and extracted data from studies. We assessed risk of bias using Cochrane and Joanna Briggs Institute tools, undertook meta-analyses, and meta-aggregation. RESULTS: 20 of 22 included studies assessed our outcomes (3 Randomised Controlled Trials (RCTs); 7 observational; 5 qualitative; 5 economic), on novel floors (N = 12), sports floors (N = 5), carpet (N = 5), and wooden sub-floors (N = 1). Quantitative data related to 11,857 patient falls (9 studies), and 163 staff injuries (1 study). One care home-based RCT found a novel underlay produced similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to a plywood underlay with vinyl overlay and concrete sub-floors. Very low-quality evidence suggested that shock-absorbing flooring may reduce injuries in hospitals (Rate Ratio 0.55, 95% CI 0.36 to 0.84, 2 studies; 27.1% vs. 42.4%; Risk Ratio (RR) = 0.64, 95% CI 0.44 to 0.93, 2 studies) and care homes (26.4% vs. 33.0%; RR 0.80, 95% CI 0.70 to 0.91, 3 studies), without increasing falls. Economic evidence indicated that if injuries are fewer and falls not increased, then shock-absorbing flooring would be a dominant strategy. Fracture outcomes were imprecise; however, hip fractures reduced from 30 in 1000 falls on concrete to 18 in 1000 falls on wooden sub-floors (OR 0.59, 95% CI 0.45 to 0.78; one study; very low-quality evidence). Staff found moving wheeled equipment harder on shock-absorbing floors leading to workplace adaptations. Very low-quality evidence suggests staff injuries were no less frequent on rigid floors. CONCLUSION: Evidence favouring shock-absorbing flooring is uncertain and of very low quality. Robust research following a core outcome set is required, with attention to wider staff workplace implications. TRIAL REGISTRATION: PROSPERO CRD42019118834 .

Injuries from falls by older adults in long-term care captured on video: Prevalence of impacts and injuries to body parts.

BACKGROUND: Falls are the leading cause of injuries in older adults. However, most falls in older adults do not cause serious injury, suggesting that older adults may fall in a manner that reduces the likelihood of impact to body sites that are most vulnerable to injury. In this observational study of falls in long-term care (LTC), we tested whether body parts differed in their probability of impact and injury. METHODS: We recorded and analyzed videos of 2388 falls by 658 LTC residents (mean age 84.0 (SD = 8.1); 56.4% female). We used Linear Mixed Models to test for differences between body parts in the probability of impact and injury, and injury when impacts occurred. RESULTS: Injuries were reported in 38.2% of falls, and 85.9% of injuries involved direct impact to the injured body part. Impact occurred most often to the hip/pelvis (probability (standard error) = 0.95 (0.01); p < .001 relative to other body parts), and least often to the head (0.35 (0.01)). Conversely, injury occurred most often to the head (p < .001 relative to other body parts). The probability of injury when impacts occurred was 0.40 (0.01) for the head, and 0.11 or less for all other body parts. CONCLUSION: Our results help to explain why most falls by older adults in LTC do not cause serious injury: residents land on body parts that are the most resilient to injury. The high susceptibility of the head to injury reinforces the need to enhance upper limb protective responses for fall arrest. The dominant role of direct impact as the mechanism of injury supports approaches to attenuate impact forces through strategies like protective clothing and compliant flooring.

The Flooring for Injury Prevention (FLIP) Study of compliant flooring for the prevention of fall-related injuries in long-term care: A randomized trial.

BACKGROUND: Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness "compliant" flooring, may prevent fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents. METHODS AND FINDINGS: The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m2, and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of ≥1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio [OR]: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or ≥2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio [RR]: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with ≥1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio [HR]: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in use throughout the study and may have influenced the observed effect of compliant flooring, and challenges with concussion detection in LTC residents may have prevented estimation of the effect of compliant flooring on fall-related concussions. CONCLUSIONS: In contrast to results from previous retrospective and nonrandomized studies, this study found that compliant flooring underneath hospital-grade vinyl was not effective at preventing serious fall-related injuries in LTC. Future studies are needed to identify effective methods for preventing fall-related injuries in LTC. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01618786.

Men on the Move: A Randomized Controlled Feasibility Trial of a Scalable, Choice-Based, Physical Activity and Active Transportation Intervention for Older Men.

We conducted Men on the Move, a 12-week randomized controlled feasibility trial of a scalable, choice-based, physical activity (PA) and active transportation intervention. Participants were community-dwelling men aged 60 years and older (n = 29 intervention [INT] and n = 29 waitlist control [CON]). Trained activity coaches delivered: (a) one-on-one participant consultations to develop personal action plans for PA and active transportation, (b) monthly group-based motivational meetings, (c) weekly telephone support, (d) complimentary recreation and transit passes, and (e) pedometers and diaries for self-monitoring. Men on the Move demonstrated high rates of recruitment, retention, and intervention adherence. INT chose a variety of group-based and individual PAs and destinations for their personal action plans. At 12 weeks, INT achieved more steps, moderate-vigorous PA, and energy expenditure than CON. INT was also more likely to take transit and meet national guideline levels of PA. At 24 weeks follow-up, INT benefits were sustained for moderate-vigorous PA and energy expenditure.

Clinical Risk Factors for Head Impact During Falls in Older Adults: A Prospective Cohort Study in Long-Term Care.

OBJECTIVE: To examine risk factors associated with head impact during falls in older adults in long-term care (LTC). SETTING: Two LTC facilities in British Columbia, Canada. PARTICIPANTS: 160 LTC residents. DESIGN: Prospective cohort study. MAIN MEASURES: Between 2007 and 2014, we video captured 520 falls experienced by participants. Each fall video was analyzed to determine whether impact occurred to the head. Using generalized estimating equation models, we examined how head impact was associated with other fall characteristics and health status prior to the fall. RESULTS: Head impact occurred in 33% of falls. Individuals with mild cognitive impairment were at higher risk for head impact (odds ratio = 2.8; 95% confidence interval, 1.5-5.0) than those with more severe cognitive impairment. Impaired vision was associated with 2.0-fold (1.3-3.0) higher odds of head impact. Women were 2.2 times (1.4-3.3) more likely than men to impact their head during a fall. CONCLUSION: Head impact is common during falls in LTC, with less cognitively impaired, female residents who suffered from visual impairment, being most likely to impact their head. Future research should focus on improving our ability to detect neural consequences of head impact and evaluating the effect of interventions for reducing the risk for fall-related head injuries in LTC.

Study protocol for the Flooring for Injury Prevention (FLIP) Study: a randomised controlled trial in long-term care.

BACKGROUND: A promising strategy for reducing the incidence and severity of fall-related injuries in long-term care (LTC) is to decrease the ground surface stiffness, and the subsequent forces applied to the body parts at impact, through installation of compliant flooring that does not substantially affect balance or mobility. Definitive evidence of the effects of compliant flooring on fall-related injuries in LTC is lacking. The Flooring for Injury Prevention (FLIP) Study is designed to address this gap. METHODS: The FLIP Study is a 4-year, parallel-group, 2-arm, randomised controlled superiority trial of flooring in 150 resident rooms at a LTC site. The primary objective is to determine whether compliant flooring reduces serious fall-related injuries relative to control flooring. Intervention (2.54 cm SmartCells compliant; 74 rooms) and control (2.54 cm plywood; 76 rooms) floorings were installed over the top of existing concrete floors and covered with identical 2.00 mm vinyl. The primary outcome is serious fall-related injury, defined as any impact-related injury due to a fall in a study room that results in Emergency Department visit or hospital admission. Secondary outcomes include minor fall-related injury, any fall-related injury, falls, number of fallers, fractures, and healthcare utilisation and costs for serious fall-related injuries. Randomisation of study rooms, and residents in rooms, was stratified by residential unit, and flooring assignments were concealed. Outcome ascertainment began September 2013. DISCUSSION: Results from the FLIP Study will provide evidence about the effects of compliant flooring on fall-related injuries in LTC and will guide development of safer environments for vulnerable older adults. TRIAL REGISTRATION NUMBER: NCT01618786.

External Hand Forces Exerted by Long-Term Care Staff to Push Floor-Based Lifts: Effects of Flooring System and Resident Weight.

OBJECTIVE: The aim of this study was to investigate the effects of flooring type and resident weight on external hand forces required to push floor-based lifts in long-term care (LTC). BACKGROUND: Novel compliant flooring is designed to reduce fall-related injuries among LTC residents but may increase forces required for staff to perform pushing tasks. A motorized lift may offset the effect of flooring on push forces. METHOD: Fourteen female LTC staff performed straight-line pushes with two floor-based lifts (conventional, motor driven) loaded with passengers of average and 90th-percentile resident weights over four flooring systems (concrete+vinyl, compliant+vinyl, concrete+carpet, compliant+carpet). Initial and sustained push forces were measured by a handlebar-mounted triaxial load cell and compared to participant-specific tolerance limits. Participants rated pushing difficulty. RESULTS: Novel compliant flooring increased initial and sustained push forces and subjective ratings compared to concrete flooring. Compared to the conventional lift, the motor-driven lift substantially reduced initial and sustained push forces and perceived difficulty of pushing for all four floors and both resident weights. Participants exerted forces above published tolerance limits only when using the conventional lift on the carpet conditions (concrete+carpet, compliant+carpet). With the motor-driven lift only, resident weight did not affect push forces. CONCLUSION: Novel compliant flooring increased linear push forces generated by LTC staff using floor-based lifts, but forces did not exceed tolerance limits when pushing over compliant+vinyl. The motor-driven lift substantially reduced push forces compared to the conventional lift. APPLICATION: Results may help to address risk of work-related musculoskeletal injury, especially in locations with novel compliant flooring.

Population attributable fraction of type 2 diabetes due to physical inactivity in adults: a systematic review.

BACKGROUND: Physical inactivity is a global pandemic. The population attributable fraction (PAF) of type 2 diabetes mellitus (T2DM) associated with physical inactivity ranges from 3% to 40%. The purpose of this systematic review was to determine the best estimate of PAF for T2DM attributable to physical inactivity and absence of sport participation or exercise for men and women. METHODS: We conducted a systematic review that included a comprehensive search of MEDLINE, EMBASE, SportDiscus, and CINAHL (1946 to April 30 2013) limited by the terms adults and English. Two reviewers screened studies, extracted PAF related data and assessed the quality of the selected studies. We reconstructed 95% CIs for studies missing these data using a substitution method. RESULTS: Of the eight studies reporting PAF in T2DM, two studies included prospective cohort studies (3 total) and six were reviews. There were distinct variations in quality of defining and measuring physical inactivity, T2DM and adjusting for confounders. In the US, PAFs for absence of playing sport ranged from 13% (95% CI: 3, 22) in men and 29% (95% CI: 17, 41) in women. In Finland, PAFs for absence of exercise ranged from 3% (95% CI: -11, 16) in men to 7% (95% CI: -9, 20) in women. CONCLUSIONS: The PAF of physical inactivity due to T2DM is substantial. Physical inactivity is a modifiable risk factor for T2DM. The contribution of physical inactivity to T2DM differs by sex; PAF also differs if physical inactivity is defined as the absence of 'sport' or absence of 'exercise'.

Longitudinal change in energy expenditure and effects on energy requirements of the elderly.

BACKGROUND: Very little is known about the longitudinal changes in energy requirements in late life. The purposes of this study were to: (1) determine the energy requirements in late life and how they changed during a 7 year time-span, (2) determine whether changes in fat free mass (FFM) were related to changes in resting metabolic rate (RMR), and (3) determine the accuracy of predicted total energy expenditure (TEE) to measured TEE. METHODS: TEE was assessed via doubly labeled water (DLW) technique in older adults in both 1999 (n = 302; age: 74 ± 2.9 yrs) and again in 2006 (n = 87 age: 82 ± 3.1 yrs). RMR was measured with indirect calorimetry, and body composition was assessed with dual-energy x-ray absorptiometry. RESULTS: The energy requirements in the 9th decade of life were 2208 ± 376 kcal/d for men and 1814 ± 337 kcal/d for women. This was a significant decrease from the energy requirements in the 8th decade of life in men (2482 ± 476 kcal/d vs. 2208 ± 376 kcal/d) but not in women (1892 ± 271 kcal/d vs. 1814 ± 337 kcal/d). In addition to TEE, RMR, and activity EE (AEE) also decreased in men, but not women, while FFM decreased in both men and women. The changes in FFM were correlated with changes in RMR for men (r = 0.49, p < 0.05) but not for women (r = -0.08, ns). Measured TEE was similar to Dietary Reference Intake (DRI) predicted TEE for men (2208 ± 56 vs. 2305 ± 35 kcal/d) and women (1814 ± 42 vs. 1781 ± 20 kcal/d). However, measured TEE was different than the World Health Organization (WHO) predicted TEE in men (2208 ± 56 vs. 2915 ± 31 kcal/d (p < 0.05)) and women (1814 ± 42 vs. 2315 ± 21 kcal/d (p < 0.05)). CONCLUSIONS: TEE, RMR and AEE decreased in men, but not women, from the 8th to 9th decade of life. The DRI equation to predict TEE was comparable to measured TEE, while the WHO equation over-predicted TEE in our elderly population.

Older Mens' Experiences with and Preferences for Physical Activity.

We aim to describe older mens' experiences with physical activity (PA) and their preferences for PA programs. We interviewed 14 men from a Canada-based PA intervention study called Men on the Move, and 5 men from a supplementary sample (who were not intervention participants). Content analysis was used to describe their experiences with PA and program preferences. The socio-ecological perspective and the hegemonic masculinity framework guided the research. PA barriers were low motivation, poor health, lack of time, interests other than PA and a lack of interest in PA, finances, lack of knowledge about PA, injury fear, social influences, inconvenience, weather, caregiving, built/natural environments, low-quality fitness instructors, and program structure. PA facilitators were chores, health, interest, time, motivation, social influences, active transportation, built/natural environments, good weather, program structure, and skilled/knowledgeable fitness instructors. PA program preferences were small group atmosphere, individualized attention/programming, equal number of men and women, sports programming, PA classes, and experienced instructors. Older men have distinct PA experiences. Promoting and designing programs that address their experiences may increase their PA.

Constricting Life Space and Likelihood of Neurodegenerative Disease in Community-Dwelling Older Men.

Importance: Life space is a measure of the frequency, range, and independence of movement through the environment. There is increasing interest in life space as a holistic measure of function in older adults, but the association between change in life space and incident neurodegenerative disease is unknown. Objective: To evaluate the association between change in life space and cognitive decline or incident neurodegenerative disease over 7 years among community-dwelling older men. Design, Setting, and Participants: In this cohort study, logistic regression analyses were used to examine the association of baseline and change in life space with change in cognition unadjusted and adjusted for demographics, cardiovascular risk factors, depression, gait speed, and physical activity. Mixed linear effects models were used to evaluate the association between change in life space and change in cognition. Men were recruited from 6 US sites to participate in a prospective, community-based cohort study of aging and followed-up from 2007 to 2014. Individuals with prevalent dementia or Parkinson disease (PD) at baseline were excluded. Data were analyzed from May 2022 to September 2023. Exposure: Life space, assessed using the University of Alabama at Birmingham Life Space Assessment and divided into tertiles. Main Outcomes and Measures: Participants completed the Modified Mini-Mental State (3MS) Test, and Trail-Making Test Part B at baseline and 7 years later. At follow-up, participants were asked about a new physician diagnosis of dementia and PD. Results: A total of 1684 men (mean [SD] age, 77.1 [4.2] years) were recruited and over 7 years of follow-up, 80 men (4.8%) developed dementia and 23 men (1.4%) developed PD. Mean (SD) life space score was 92.9 (18.7) points and mean (SD) change was -9.9 (22.3) points over follow up. In the adjusted model, each 1-SD decrement in life space was associated with increased odds of dementia (odds ratio [OR], 1.59; 95% CI, 1.28-1.98) but not PD (OR, 1.48; 95% CI, 0.97-2.25). For each 1-SD decrement in life space, men worsened by 20.6 (95% CI, 19.8-21.1) seconds in their Trails B score (P < .001) and declined by 1.2 (95% CI, 1.0-1.3) points in their 3MS score (P < .001) over 7 years. Conclusions and Relevance: In this study of 1684 men followed up over 7 years, change in life space was associated with faster cognitive decline and increased likelihood of neurodegenerative illness. Future studies should examine the role of clinician assessments or wearable electronics in tracking life space in older adults at risk of cognitive decline and neurodegenerative illness.

Quantifying Physical Resilience in Ageing Using Measurement Instruments: A Scoping Review.

Purpose: The capacity to recover motor function with pathology or age-related decline is termed physical resilience. It is unknown what outcome domains are captured with existing measurement instruments. Thus, this scoping review aimed to identify measurement instruments for physical resilience, identify research gaps, and make recommendations for future research. Methods: Articles were included from the search when their subject matter included the term resilience in relation to the physical health of older adults. Data on physical resilience measurement instruments were extracted using the outcome domains: body function or structure, activity and participation, and societal impact. Results: The majority of the 33 included articles involved older adults with fractures, cardiac conditions, and cancer. Many measurement instruments quantified body function or structure, and some instruments captured activity and participation, and societal impact of physical resilience. Measurement instruments were pooled into 4 categories: psychological, physiological, motor function, and psychosocial scales. No studies combined all areas of measurement. Conclusions: A potential gap of a measurement instrument capturing social aspects of physical resilience was identified. Comprehensive measurement could identify which outcome domains could be targeted to foster resilience. This knowledge might be useful across many health disciplines and contribute to therapeutic decision-making and rehabilitation strategies.

Objectif : la résilience physique désigne la capacité de recouvrer sa fonction motrice malgré le déclin lié à une pathologie ou à l'âge. On ne sait pas quels domaines de résultats cliniques les instruments de mesure actuels saisissent. Ainsi, la présente étude de portée visait à déterminer les instruments pour mesurer la résilience physique, repérer les lacunes de la recherche et faire des recommandations en vue des futures recherches. Méthodologie : les articles de la recherche étaient conservés lorsque leur sujet incluait le terme resilience à l'égard de la santé physique des personnes âgées. Les chercheurs ont extrait les données sur les instruments de mesure de la résilience physique au moyen des domaines de résultats suivants : fonction ou structure corporelle, l'activité et la participation et les répercussions sociétales. Résultats : la majorité des 33 articles inclus portaient sur des personnes âgées ayant des fractures, des affections cardiaques et un cancer. De nombreux instruments de mesure quantifiaient la fonction ou la structure corporelle et certains saisissaient l'activité, la participation et les répercussions sociétales de la résilience physique. Les chercheurs ont regroupé les instruments de mesure en quatre catégories : échelles psychologique, physiologique, de la fonction motrice et psychosociale. Aucune étude ne combinait tous les domaines de mesure. Conclusions : les chercheurs ont repéré une lacune potentielle d'un instrument qui saisit les aspects sociaux de la résilience physique. Une mesure exhaustive pourrait déterminer les domaines de résultat à cibler pour favoriser la résilience. Ces connaissances pourraient être utiles dans de nombreuses disciplines et contribuer aux décisions thérapeutiques et aux stratégies de réadaptation.

Shock-absorbing flooring for fall-related injury prevention in older adults and staff in hospitals and care homes: the SAFEST systematic review.

BACKGROUND: Injurious falls in hospitals and care homes are a life-limiting and costly international issue. Shock-absorbing flooring may offer part of the solution; however, evidence is required to inform decision-making. OBJECTIVES: The objectives were to assess the clinical effectiveness and cost-effectiveness of shock-absorbing flooring for fall-related injury prevention among older adults in care settings. REVIEW METHODS: A systematic review was conducted of experimental, observational, qualitative and economic studies evaluating flooring in care settings targeting older adults and/or staff. Studies identified by a scoping review (inception to May 2016) were screened, and the search of MEDLINE, AgeLine and Scopus (to September 2019) was updated, alongside other sources. Two independent reviewers assessed risk of bias in duplicate (using Cochrane's Risk of Bias 2.0 tool, the Risk Of Bias In Non-randomized Studies - of Interventions tool, or the Joanna Briggs Institute's qualitative tool). RESULTS: Of the 22 included studies, 20 assessed the outcomes (three randomised controlled trials; and seven observational, five qualitative and five economic studies) on novel floors (n = 12), sports floors (n = 5), carpet (n = 5) and wooden subfloors (n = 1). Quantitative data related to 11,857 patient/resident falls (nine studies) and 163 staff injuries (one study). Qualitative studies included patients/residents (n = 20), visitors (n = 8) and staff (n = 119). Hospital-based randomised controlled trial data were too imprecise; however, very low-quality evidence indicated that novel/sports flooring reduced injurious falls from three per 1000 patients per day on vinyl with concrete subfloors to two per 1000 patients per day (rate ratio 0.55, 95% confidence interval 0.36 to 0.84; two studies), without increasing falls rates (two studies). One care home-based randomised controlled trial found that a novel underlay produces similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to those of a plywood underlay with vinyl overlays and concrete subfloors. Very low-quality data demonstrated that, compared with rigid floors, novel/sports flooring reduced the number of falls resulting in injury in care homes (26.4% vs. 33.0%; risk ratio 0.80, 95% confidence interval 0.70 to 0.91; three studies) and hospitals (27.1% vs. 42.4%; risk ratio 0.64, 95% confidence interval 0.44 to 0.93; two studies). Fracture and head injury outcomes were imprecise; however, hip fractures reduced from 30 per 1000 falls on concrete to 18 per 1000 falls on wooden subfloors in care homes (odds ratio 0.59, 95% confidence interval 0.45 to 0.78; one study; very low-quality evidence). Four low-quality economic studies concluded that shock-absorbing flooring reduced costs and improved outcomes (three studies), or increased costs and improved outcomes (one study). One, more robust, study estimated that shock-absorbing flooring resulted in fewer quality-adjusted life-years and lower costs, if the number of falls increased on shock-absorbing floors, but that shock-absorbing flooring would be a dominant economic strategy if the number of falls remained the same. Staff found moving wheeled equipment more difficult on shock-absorbing floors, leading to workplace adaptations. Staff injuries were observed; however, very low-quality evidence suggests that these are no less frequent on rigid floors. LIMITATIONS: Evidence favouring shock-absorbing flooring is of very low quality; thus, much uncertainty remains. CONCLUSIONS: Robust evidence is lacking in hospitals and indicates that one novel floor may not be effective in care homes. Very low-quality evidence indicates that shock-absorbing floors may be beneficial; however, wider workplace implications need to be addressed. Work is required to establish a core outcome set, and future research needs to more comprehensively deal with confounding and the paucity of hospital-based studies, and better plan for workplace adaptations in the study design. STUDY REGISTRATION: This study is registered as PROSPERO CRD42019118834. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 5. See the NIHR Journals Library website for further project information.

AIM: The aim of this study was to summarise what is known about shock-absorbing flooring for reducing injurious falls in hospitals and care homes. BACKGROUND: Falls and fall-related injuries are a major problem for older adults in both hospitals and care homes. Shock-absorbing flooring (such as carpet, sports floors or specially designed floors) provides a more cushioned surface and is one potential solution to help reduce the impact forces from a fall. METHODS: From literature searches, we identified relevant studies on shock-absorbing flooring use in hospitals and care homes. We gathered data on the quality of the studies' methods, what and who the studies involved, and the study findings. Members of the public were involved throughout the project. They helped improve the clarity of the reporting and collaborated in meetings to help guide the study team. FINDINGS: One high-quality study in a care home found that vinyl overlay with novel shock-absorbing underlay was no better at reducing injuries than vinyl overlay with plywood underlay on concrete subfloors. We found very low-quality evidence that shock-absorbing flooring may reduce injuries in hospitals and care homes, without increasing falls; if this were true, then economic evidence suggested that shock-absorbing flooring would be the best-value option for patients (lower cost and improved outcomes). There was insufficient evidence to determine the effects of shock-absorbing flooring on fractures or head injuries, although wooden subfloors resulted in fewer hip fractures than concrete subfloors. Shock-absorbing flooring made it harder for staff to move equipment such as beds and trolleys, and led to staff changing how they work. IMPLICATIONS: The evidence suggests that one type of shock-absorbing floor may not work in care homes, compared with rigid flooring; however, gaps still exist in the knowledge. The evidence in favour of shock-absorbing flooring was of very low quality, meaning it is uncertain. There is a lack of robust evidence in hospitals, which often have concrete subfloors and different population characteristics. If planning to install shock-absorbing flooring, it is important to consider the wider impacts on the workplace and how best to manage these.

Usual physical activity and hip fracture in older men: an application of semiparametric methods to observational data.

Few studies have examined the relation between usual physical activity level and rate of hip fracture in older men or applied semiparametric methods from the causal inference literature that estimate associations without assuming a particular parametric model. Using the Physical Activity Scale for the Elderly, the authors measured usual physical activity level at baseline (2000-2002) in 5,682 US men ≥65 years of age who were enrolled in the Osteoporotic Fractures in Men Study. Physical activity levels were classified as low (bottom quartile of Physical Activity Scale for the Elderly score), moderate (middle quartiles), or high (top quartile). Hip fractures were confirmed by central review. Marginal associations between physical activity and hip fracture were estimated with 3 estimation methods: inverse probability-of-treatment weighting, G-computation, and doubly robust targeted maximum likelihood estimation. During 6.5 years of follow-up, 95 men (1.7%) experienced a hip fracture. The unadjusted risk of hip fracture was lower in men with a high physical activity level versus those with a low physical activity level (relative risk = 0.51, 95% confidence interval: 0.28, 0.92). In semiparametric analyses that controlled confounding, hip fracture risk was not lower with moderate (e.g., targeted maximum likelihood estimation relative risk = 0.92, 95% confidence interval: 0.62, 1.44) or high (e.g., targeted maximum likelihood estimation relative risk = 0.88, 95% confidence interval: 0.53, 2.03) physical activity relative to low. This study does not support a protective effect of usual physical activity on hip fracture in older men.

Formative Evaluation of Consumer-Grade Activity Monitors Worn by Older Adults: Test-Retest Reliability and Criterion Validity of Step Counts.

BACKGROUND: To assess whether commercial-grade activity monitors are appropriate for measuring step counts in older adults, it is essential to evaluate their measurement properties in this population. OBJECTIVE: This study aimed to evaluate test-retest reliability and criterion validity of step counting in older adults with self-reported intact and limited mobility from 6 commercial-grade activity monitors: Fitbit Charge, Fitbit One, Garmin vívofit 2, Jawbone UP2, Misfit Shine, and New-Lifestyles NL-1000. METHODS: For test-retest reliability, participants completed two 100-step overground walks at a usual pace while wearing all monitors. We tested the effects of the activity monitor and mobility status on the absolute difference in step count error (%) and computed the standard error of measurement (SEM) between repeat trials. To assess criterion validity, participants completed two 400-meter overground walks at a usual pace while wearing all monitors. The first walk was continuous; the second walk incorporated interruptions to mimic the conditions of daily walking. Criterion step counts were from the researcher tally count. We estimated the effects of the activity monitor, mobility status, and walk interruptions on step count error (%). We also generated Bland-Altman plots and conducted equivalence tests. RESULTS: A total of 36 individuals participated (n=20 intact mobility and n=16 limited mobility; 19/36, 53% female) with a mean age of 71.4 (SD 4.7) years and BMI of 29.4 (SD 5.9) kg/m2. Considering test-retest reliability, there was an effect of the activity monitor (P<.001). The Fitbit One (1.0%, 95% CI 0.6% to 1.3%), the New-Lifestyles NL-1000 (2.6%, 95% CI 1.3% to 3.9%), and the Garmin vívofit 2 (6.0%, 95 CI 3.2% to 8.8%) had the smallest mean absolute differences in step count errors. The SEM values ranged from 1.0% (Fitbit One) to 23.5% (Jawbone UP2). Regarding criterion validity, all monitors undercounted the steps. Step count error was affected by the activity monitor (P<.001) and walk interruptions (P=.02). Three monitors had small mean step count errors: Misfit Shine (-1.3%, 95% CI -19.5% to 16.8%), Fitbit One (-2.1%, 95% CI -6.1% to 2.0%), and New-Lifestyles NL-1000 (-4.3%, 95 CI -18.9% to 10.3%). Mean step count error was larger during interrupted walking than continuous walking (-5.5% vs -3.6%; P=.02). Bland-Altman plots illustrated nonsystematic bias and small limits of agreement for Fitbit One and Jawbone UP2. Mean step count error lay within an equivalence bound of ±5% for Fitbit One (P<.001) and Misfit Shine (P=.001). CONCLUSIONS: Test-retest reliability and criterion validity of step counting varied across 6 consumer-grade activity monitors worn by older adults with self-reported intact and limited mobility. Walk interruptions increased the step count error for all monitors, whereas mobility status did not affect the step count error. The hip-worn Fitbit One was the only monitor with high test-retest reliability and criterion validity.

Protocol for the SAFEST review: the Shock-Absorbing Flooring Effectiveness SysTematic review including older adults and staff in hospitals and care homes.

INTRODUCTION: Falls in hospitals and care homes are a major issue of international concern. Inpatient falls are the most commonly reported safety incident in the UK's National Health Service (NHS), costing the NHS £630 million a year. Injurious falls are particularly life-limiting and costly. There is a growing body of evidence on shock-absorbing flooring for fall-related injury prevention; however, no systematic review exists to inform practice. METHODS AND ANALYSIS: We will systematically identify, appraise and summarise studies investigating the clinical and cost-effectiveness, and experiences of shock-absorbing flooring in hospitals and care homes. Our search will build on an extensive search conducted by a scoping review (inception to May 2016). We will search electronic databases (AgeLine, CINAHL, MEDLINE, NHS Economic Evaluation Database, Scopus and Web of Science; May 2016-present), trial registries and grey literature. We will conduct backward and forward citation searches of included studies, and liaise with study researchers. We will evaluate the influence of floors on fall-related injuries, falls and staff work-related injuries through randomised and non-randomised studies, consider economic and qualitative evidence, and implementation factors. We will consider risk of bias, assess heterogeneity and explore potential effect modifiers via subgroup analyses and sensitivity analyses. Where appropriate we will combine studies through meta-analysis. We will use the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach to evaluate the quality of evidence and present the results using summary of findings tables, and adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. ETHICS AND DISSEMINATION: We will follow the ethical principles of systematic review conduct, by attending to publication ethics, transparency and rigour. Our dissemination plan includes peer-reviewed publication, presentations, press release, stakeholder symposium, patient video and targeted knowledge-to-action reports. This review will inform decision-making around falls management in care settings and identify important directions for future research. PROSPERO REGISTRATION NUMBER: CRD42019118834.

Activity energy expenditure and mobility limitation in older adults: differential associations by sex.

In this study, the authors aimed to determine whether higher activity energy expenditure, assessed by using doubly labeled water, was associated with a reduced decline in mobility limitation among 248 older community-dwelling US adults aged 70-82 years enrolled in 1998-1999. Activity energy expenditure was calculated as total energy expenditure (assessed over 2 weeks by using doubly labeled water) minus resting metabolic rate (measured with indirect calorimetry), with adjustment for the thermic effect of food. Across sex-specific tertiles of activity energy expenditure, men in the lowest activity group experienced twice the rate of mobility limitation as men in the highest activity group (41% (n = 18) vs. 18% (n = 8)). Conversely, women in the lowest and highest activity groups exhibited similarly high rates of mobility limitation (40% (n = 16) vs. 38% (n = 15)). After adjustment for potential confounders, men with higher activity energy expenditure levels continued to show reduced risk of mobility limitation (per standard deviation (284 kcal/day): hazard ratio = 0.61, 95% confidence interval: 0.41, 0.92). Women showed no association (per standard deviation (226 kcal/day): hazard ratio = 1.34, 95% confidence interval: 0.98, 1.85). Greater energy expenditure from any and all physical activity was significantly associated with reduced risk of developing mobility limitation among men, but not among women.