Qualitative Comparative Analysis of exercise interventions for fall prevention in residential aged care facilities.

BACKGROUND: Exercise interventions are highly effective at preventing falls in older people living in the community. In residential aged care facilities (RACFs), however, the evidence for effectiveness is highly variable, warranting exploration of drivers of successful trials. This study aims to identify the conditions of randomised controlled trials (RCTs) that are associated with reducing falls in RACFs and test whether it can explain the variability. METHODS: RCTs testing exercise interventions in RACFs compared to usual care, reporting rate or risk of falls from the 2018 Cochrane Collaboration review and a search update to December 2022 were included. Two authors independently extracted and coded trial conditions and outcomes according to a theory developed from prior Intervention Component Analysis. Trial outcomes were coded as successful or unsuccessful based on point estimates for the rate or risk ratio for falls, or p value. Qualitative Comparative Analysis (QCA), utilising Boolean minimisation theory, was conducted to determine the key conditions driving trial success. A subgroup meta-analysis and the GRADE approach was applied to the final theory. RESULTS: Eighteen trials undertaken in 11 countries with 2,287 residents were included. Participants were predominately ambulant females aged 70 to 80 with cognitive impairment. Most interventions were fully supervised or supervised at the start of the intervention. QCA identified two configurations as drivers of successful exercise falls prevention programs: (i) group exercise that is moderate or low intensity, or (ii) for independent ambulatory residents, exercise for more than 1 h per week. The combination of configuration (i) and (ii) had consistency and total coverage scores of 1, indicating all trials were explained. This combination was associated with a reduction in falls (rate ratio 0.45, 95%CI 0.34 to 0.59; risk ratio 0.66, 95%CI 0.53 to 0.82; low certainty evidence). CONCLUSION: To successfully reduce falls in RACFs, exercise programs should provide continuous supervised moderate-intensity group exercise. For programs that mostly include independent ambulatory residents, exercise for at least 80 min per week should be provided. As many current residents are frail, tailored exercise is likely necessary and an individualised dose may be required. Future trials should test exercise interventions for less mobile residents.

Effective fall prevention exercise in residential aged care: an intervention component analysis from an updated systematic review.

OBJECTIVE: The effect of fall prevention exercise programmes in residential aged care (RAC) is uncertain. This paper reports on an intervention component analysis (ICA) of randomised controlled trials (RCTs), from an update of a Cochrane review, to develop a theory of features of successful fall prevention exercise in RAC. METHODS: Trial characteristics were extracted from RCTs testing exercise interventions in RAC identified from an update of a Cochrane review to December 2022 (n=32). Eligible trials included RCTs or cluster RCTs in RAC, focusing on participants aged 65 or older, assessing fall outcomes with stand-alone exercise interventions. ICA was conducted on trials with >30 participants per treatment arm compared with control (n=17). Two authors coded trialists' perceptions on intervention features that may have contributed to the observed effect on falls. Inductive thematic analysis was used to identify the key differences between the trials which might account for positive and negative outcomes. RESULTS: 32 RCTs involving 3960 residents including people with cognitive (57%) and mobility (41%) impairments were included. ICA on the 17 eligible RCTs informed the development of a theory that (1) effective fall prevention exercise delivers the right exercise by specifically targeting balance and strength, tailored to the individual and delivered simply at a moderate intensity and (2) successful implementation needs to be sufficiently resourced to deliver structured and supervised exercise at an adequate dose. CONCLUSIONS: This analysis suggests that delivering the right exercise, sufficiently resourced, is important for preventing falls in RAC. This clinical guidance requires confirmation in larger trials.

Exercise Interventions Delivered Through Telehealth to Improve Physical Functioning for Older Adults with Frailty, Cognitive, or Mobility Disability: A Systematic Review and Meta-Analysis.

Introductions: This study assessed the effects of telehealth-delivered exercise interventions on physical functioning for older adults and explored implementation measures related to program delivery. Methods: We conducted a systematic review of studies investigating effects of exercise interventions delivered through telehealth in adults 60+ years of age with frailty, mobility, or cognitive disability on mobility, strength, balance, falls, and quality of life (QoL). Electronic databases (MEDLINE, CINAHL, SPORTSDiscus, and Physiotherapy Evidence Database) were searched from inception until May 2022. Evidence certainty was assessed with Grading of Recommendations, Assessment, Development, and Evaluation and meta-analysis summarized study effects. Results: A total of 11 studies were included, 5 randomized controlled trials, 2 pilot studies, and 4 feasibility studies. The overall certainty of evidence was rated as "low" or "very low." Pooled between-group differences were not statistically significant, but effect sizes suggested that telehealth produced a moderate improvement on mobility (n = 5 studies; standardized mean difference [SMD] = 0.63; 95% confidence interval [CI] = -0.25 to 1.51; p = 0.000, I2 = 86%) and strength (n = 4; SMD = 0.73; 95% CI = -0.10 to 1.56; p = 0.000, I2 = 84%), a small improvement on balance (n = 3; SMD = 0.40; 95% CI = -035 to 1.15; p = 0.012, I2 = 78%), and no effect on QoL. Analysis of implementation measures suggested telehealth to be feasible in this population, given high rates of acceptability and adherence with minimal safety concerns. Discussion: Telehealth may provide small to moderate benefits on a range of physical outcomes and appears to be well received in aged care populations.

Exercise for falls prevention in aged care: systematic review and trial endpoint meta-analyses.

BACKGROUND: There is strong evidence that exercise reduces falls in older people living in the community, but its effectiveness in residential aged care is less clear. This systematic review examines the effectiveness of exercise for falls prevention in residential aged care, meta-analysing outcomes measured immediately after exercise or after post-intervention follow-up. METHODS: Systematic review and meta-analysis, including randomised controlled trials from a Cochrane review and additional trials, published to December 2022. Trials of exercise as a single intervention compared to usual care, reporting data suitable for meta-analysis of rate or risk of falls, were included. Meta-analyses were conducted according to Cochrane Collaboration methods and quality of evidence rated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: 12 trials from the Cochrane review plus 7 new trials were included. At the end of the intervention period, exercise probably reduces the number of falls (13 trials, rate ratio [RaR] = 0.68, 95% confidence interval [CI] = 0.49-0.95), but after post-intervention follow-up exercise had little or no effect (8 trials, RaR = 1.01, 95% CI = 0.80-1.28). The effect on the risk of falling was similar (end of intervention risk ratio (RR) = 0.84, 95% CI = 0.72-0.98, 12 trials; post-intervention follow-up RR = 1.05, 95% CI = 0.92-1.20, 8 trials). There were no significant subgroup differences according to cognitive impairment. CONCLUSIONS: Exercise is recommended as a fall prevention strategy for older people living in aged care who are willing and able to participate (moderate certainty evidence), but exercise has little or no lasting effect on falls after the end of a programme (high certainty evidence).

Experiences of Older Adults, Physiotherapists, and Aged Care Staff in the TOP UP Telephysiotherapy Program: Interview Study of the TOP UP Interventions.

BACKGROUND: Telehealth provides opportunities for older adults to access health care. However, limited research exists on the use of telehealth within aged care services, particularly regarding physiotherapy-led fall prevention and mobility programs. Understanding the experiences and interactions of older adults, physiotherapists, and aged care service providers is crucial for the scale-up and sustainability of such essential programs. The TOP UP study, a hybrid type 1 effectiveness-implementation randomized controlled trial in aged care, used a supported multidisciplinary telephysiotherapy model to motivate older adults to engage in exercises to improve mobility and reduce falls. OBJECTIVE: This qualitative substudy aims to achieve 2 primary objectives: to describe the experiences and acceptability of the TOP UP intervention for older people, physiotherapists, and aged care support workers and managers and to gain an in-depth understanding of program implementation. METHODS: A purposive recruitment strategy was used to select 18 older adults who participated in the TOP UP intervention, ensuring variation in age, gender, residential status (home or residential aged care), geographic location, and cognitive levels. In addition, 7 physiotherapists, 8 aged care support workers, and 6 managers from 7 different aged care provider partners participated in this study. Semistructured interviews were conducted to explore stakeholders' experiences with the TOP UP program, gather suggestions for improvement, and obtain insights for the future implementation of similar telephysiotherapy programs. The interview framework and coding processes were informed by behavior changes and implementation frameworks. Data were analyzed using an abductive approach, informed by 2 behavioral change theories (Capability, Opportunity, Motivation, and Behavior Model and Self-Determination Theory) and the Nonadoption, Abandonment and Challenges to the Scale-Up, Spread and Sustainability of Health and Care Technologies framework. RESULTS: All participants (n=39) reported high levels of acceptability for the TOP UP program and cited multiple perceived benefits. The thematic analysis generated 6 main themes: telephysiotherapy expands opportunity; tailored physiotherapy care with local support enhances motivation; engaging, older adult-friendly educational resources build capability; flexible reablement approach fosters autonomy; telephysiotherapy is safe, effective, and acceptable for many; and organizational commitment is required to embed telehealth. The motivation to exercise was enhanced by Zoom's convenience, use of tailored web-based exercise resources, and companionable local support. CONCLUSIONS: This study highlights the inherent value of telephysiotherapy in aged care, emphasizing the need for investment in staff training, local support, and older adult-friendly resources in future telephysiotherapy iterations. TOP UP represents a convenient and flexible web-based care model that empowers many older adults to receive sustainable, high-quality care precisely when and where they need it. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN 1261000734864; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621000734864.

Monitoring falls in residential aged care facilities: Agreement between falls incident reports and progress notes.

OBJECTIVES: Accurate fall reporting is essential for assessing the effectiveness of fall prevention strategies. This study aimed to investigate the level of agreement between incident reports and resident progress notes as data sources for falls monitoring in residential aged care facilities. METHODS: A retrospective observational study was conducted involving 46 older people from six residential aged care facilities who had consented to join the broader TOP UP trial. Fall events documented in the incident report system and resident progress notes over 12 months before randomisation were extracted by two independent reviewers using a standardised Excel form. Agreement between the two data collection methods was calculated using Cohen's kappa coefficient. RESULTS: A total of 75 falls were recorded from 27 (59%) of the 46 participants who were 65% female, with an average age of 83 [SD 9] years. The incident reports captured 68 (90.7%) falls, while the progress notes captured 73 (97.3%) falls. Overall, there was a 75% agreement between falls recorded in progress notes and incident reports. Perfect agreement was identified for five facilities (n = 35), while one facility had a lower agreement rate of 29% (n = 11), which appeared to be attributable to staff shortages linked to the COVID-19 pandemic. CONCLUSIONS: There was substantial agreement between incident reports and progress records. These findings support the use of incident reports for identifying falls in research or to investigate the effectiveness of fall prevention strategies in residential aged care facilities.

Physiotherapy-led telehealth and exercise intervention to improve mobility in older people receiving aged care services (TOP UP): protocol for a randomised controlled type 1 hybrid effectiveness-implementation trial.

Introduction: Deteriorating mobility and falls reduce independence and quality of life for older people receiving aged care services. This trial aims to establish effectiveness on the mobility of older people, and explore cost-effectiveness and implementation of a telehealth physiotherapy programme. Method and analysis: This type 1 hybrid effectiveness-implementation randomised controlled trial will involve 240 people aged 65+ years receiving aged care services in community or residential settings. Participants will be randomised to either: (1) the Telehealth Physiotherapy for Older People (TOP UP) Program or (2) a wait-list control group. The 6-month intervention includes 10 physiotherapy sessions delivered by videocall (Zoom). The intervention will include the local support of an aged care worker and online exercise resources. Primary outcome is mobility at 6 months post randomisation measured by the Short Physical Performance Battery. Secondary outcomes include rate of falls, sit-to-stand, quality of life, and goal attainment at 6 months after randomisation. Regression models will assess the effect of group allocation on mobility and the other continuously scored secondary outcomes, adjusting for baseline scores. The number of falls per person over 6 months will be analysed using negative binomial regression models to estimate between-group differences. An economic analysis will explore the cost-effectiveness of the TOP UP programme compared with usual care. Implementation outcomes and determinants relating to the intervention's reach, fidelity, exercise dose delivered, adoption, feasibility, acceptability, barriers and facilitators will be explored using mixed methods. Conclusion: This is the first trial to investigate the effectiveness, cost-effectiveness and implementation of a physiotherapy intervention in aged care delivered solely by telehealth internationally. The study has strong aged care co-design and governance and is guided by steering and advisory committees that include staff from aged care service providers and end-users. Trial results will be disseminated via peer-reviewed articles, conference presentations and lay summaries. Trial registration number: The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12621000734864).