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 to 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' intervention to support falls rehabilitation when delivered in practice (2) assess study design and trial procedures for the evaluation of the intervention. Methods A two-arm, pragmatic feasibility randomised 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 drop-out). Outcome measures include balance, function, falls, strength, fear of falling, health related quality of life, resource use and adherence, measured at baseline, three and six month post-randomisation. Blinded assessors collected the outcome measures. Results 24 patients were randomised to control group, 26 to intervention group, mean age 77.6 (Range 62 to 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 rate for outcome measures at six months were 77%-80% across outcome measures, but this was effected by the COVID19 pandemic. There was a mean 2.6 ± 1.9 point difference between groups in change in BERG balance score from baseline to three months and mean 4.4 ± 2.7 point difference from baseline to six 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 six months (15.3 ± 7.8 vs 14.9 ± 7.8). 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.

Palliative and end of life care Experiences of people of African and Caribbean dEscent during COVID-19 (PEACE)

What we knewPeople of African and Caribbean descent are less likely to access palliative and end of life care. It is unclear why they are so poorly served by our services and how COVID-19 has exacerbated this.What we wanted to knowWe sought bereaved relatives’, health and social care professionals’ and community workers’ views on experiences of and barriers to palliative and end of life care and suggestions for improvement.MethodsPublic recruitment was utilised. Over 150 diverse organisations throughout the UK were contacted. Qualitative semi-structured interviews were conducted with a diverse sample of 26 bereaved relatives and 13 professionals.FindingsThere were three key themes:Representation, encompassing discrimination and racism.Personalisation, including culture and the impact of COVID-19.Awareness and Access, including support before and after death and communication and involvement in decision-making.Participants recommend services shouldRepresentIdentify and acknowledge racism and discrimination in palliative care provision.Ensure better representation of African and Caribbean communities within services and in public facing material.PersonaliseAdapt services to ensure they are culturally and religiously competent:Recognise diversity in cultural and religious needs.Challenge racial and cultural stereotypes.Enable equitable remote engagement.Ensure awareness and educationBetter integrate services within communities by working with faith/community leaders.Raise awareness of the value of palliative care services in all communities.Provide training/education for professionals to build confidence and competence.ConclusionPalliative care was perceived as inadequate during the pandemic. Inequities in care provision were exacerbated, to the detriment of people of African and Caribbean descent who were disproportionately and uniquely effected. Palliative care services and local communities could and should learn from each other, to enhance equitable access to appropriate care for all. Significant investment in services and communities may be required.

The impact of COVID-19 lockdowns on physical activity amongst older adults: evidence from longitudinal data in the UK.

BACKGROUND: A sedentary lifestyle increases the risk of adverse health outcomes and frailty,particularly for older adults. To reduce transmission during the COVID-19 pandemic, people were instructed to stay at home, group sports were suspended, and gyms were closed, thereby limiting opportunities for physical activity. Whilst evidence suggests that physical activity levels reduced during the pandemic, it is unclear whether the proportion of older adults realising the recommended minimum level of physical activity changed throughout the various stages of lockdown. METHODS: We used a large sample of 3,660 older adults (aged ≥ 65) who took part in the UK Household Longitudinal Study's annual and COVID-19 studies. We examined changes in the proportion of older adults who were realising the UK Chief Medical Officers' physical activity recommendations for health maintenance at several time points before and after COVID-19 lockdowns were imposed. We stratified these trends by the presence of health conditions, age, neighbourhood deprivation, and pre-pandemic activity levels. RESULTS: There was a marked decline in older adults' physical activity levels during the third national lockdown in January 2021. The proportion realising the Chief Medical Officers' physical activity recommendations decreased from 43% in September 2020 to 33% in January 2021. This decrease in physical activity occurred regardless of health condition, age, neighbourhood deprivation, or pre-pandemic activity levels. Those doing the least activity pre-lockdown increased their activity during lockdowns and those doing the most decreased their activity levels. CONCLUSIONS: Reductions in older adults' physical activity levels during COVID-19 lockdowns have put them at risk of becoming deconditioned and developing adverse health outcomes. Resources should be allocated to promote the uptake of physical activity in older adults to reverse the effects of deconditioning.

Improving discussions about resuscitation in COVID-19

AimsThis research aims to understand relatives’ and carers’ experiences of discussions about resuscitation. Findings are needed to inform policy and practice about what works well and how discussions about resuscitation need to improve.BackgroundDo Not Attempt Cardiopulmonary Resuscitation (DNACPR) discussions have been especially challenging during the pandemic. Hospital visiting restrictions and untimely deaths due to COVID-19 have disrupted usual modes of communication between staff, patients and relatives. There have been reports of blanket DNACPR decisions being applied to older people and complaints about communication are common. This is distressing for patients and families and costly for the NHS.MethodsThis qualitative research uses semi-structured interviews to explore the experiences of people who discussed resuscitation on behalf of a relative during the COVID-19 pandemic. An interview topic guide was developed in collaboration with patients and public involvement partners. Interviews were transcribed verbatim, and analysed using framework analysis.Results18 semi-structured interviews have been undertaken to date. Analysis has identified the following themes:The importance of communication. This includes the timing of communication about DNACPR and examples of good practice and the lack of information about DNACPR for patients and families.The multiple dimensions of resuscitation and DNACPR, with misunderstanding about what resuscitation involves, how the decision about DNACPR is made, and by whom.Wide-ranging impacts of the DNACPR decision, feeling overlooked and disregarded by the medical team, guilt at not contesting a DNACPR decision, and consequent mistrust of the healthcare system.We aim to complete over 30 interviews by March 2022. Recruitment will continue until inductive thematic saturation.ConclusionUrgent action is needed to improve communication and ensure appropriate DNACPR discussions. Current practice results in frequent misunderstandings and lasting negative effects which may have detrimental consequences for bereavement reactions and future relationships with healthcare professionals.

Make Movement Your Mission: Evaluation of an online digital health initiative to increase physical activity in older people during the COVID-19 pandemic

Objective To formatively evaluate the Make Movement Your Mission (MMYM) digital health initiative to promote physical activity (PA) levels and help avert the negative consequences of sedentary behaviours in older adults during the SARS-CoV2 pandemic. Methods Mixed-method study to explore activity levels, changes in physical function and Activities of Daily Living (ADLs), quality-of-life, social engagement, technology use, and accessibility. Survey data were analysed descriptively. Qualitative interviews were analysed using framework analysis. Results Forty-one respondents completed the survey (Mean age 68.4 (8.9) years;34 Female), 68% aged ≥ 65 years. Average attendance was 14.3 sessions per week (3.5 h). 73% had been with MMYM for >1 year, 90% reported they were engaging in more movement on a typical day, and 75% reported improvement in ability to perform moderate PA. Since starting MMYM, participation in activities targeting strength, balance and flexibility increased (by 48%, 73% and 75%, respectively). 83% met strength and 90% balance PA guidelines for health (≥ 2x per week). Between 18% and 53% of respondents reported improvements in ADLs, 53% reported better quality-of-life, and 28% increased use of the internet. Eight participants were interviewed (Mean age 70.7 (6.7) years;7 Female). Activity levels were promoted by having direct support from the instructor through Facebook messages pre and post live sessions, having group expectation about quality and level of engagement, having a sense of control and encouragement from others, MMYMs regularity, choice around level of engagement and accessibility. Noticing short-term outcomes in balance and posture helped boost confidence and continued participation. Conclusion Clinical trials need to robustly assess its effectiveness and acceptability.

Effects of Digital Technologies on Older People's Access to Health and Social Care: Umbrella Review.

BACKGROUND: The 2020 COVID-19 pandemic prompted the rapid implementation of new and existing digital technologies to facilitate access to health and care services during physical distancing. Older people may be disadvantaged in that regard if they are unable to use or have access to smartphones, tablets, computers, or other technologies. OBJECTIVE: In this study, we synthesized evidence on the impact of digital technologies on older adults' access to health and social services. METHODS: We conducted an umbrella review of systematic reviews published from January 2000 to October 2019 using comprehensive searches of 6 databases. We looked for reviews in a population of adults aged ≥65 years in any setting, reporting outcomes related to the impact of technologies on access to health and social care services. RESULTS: A total of 7 systematic reviews met the inclusion criteria, providing data from 77 randomized controlled trials and 50 observational studies. All of them synthesized findings from low-quality primary studies, 2 of which used robust review methods. Most of the reviews focused on digital technologies to facilitate remote delivery of care, including consultations and therapy. No studies examined technologies used for first contact access to care, such as online appointment scheduling. Overall, we found no reviews of technology to facilitate first contact access to health and social care such as online appointment booking systems for older populations. CONCLUSIONS: The impact of digital technologies on equitable access to services for older people is unclear. Research is urgently needed in order to understand the positive and negative consequences of digital technologies on health care access and to identify the groups most vulnerable to exclusion.

Implementation of the StandingTall programme to prevent falls in older people: a process evaluation protocol.

INTRODUCTION: One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. METHODS AND ANALYSIS: This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. TRIAL REGISTRATION NUMBER: ACTRN12619001329156.

Safety, Reactogenicity, and Health-Related Quality of Life After Trivalent Adjuvanted vs Trivalent High-Dose Inactivated Influenza Vaccines in Older Adults: A Randomized Clinical Trial.

Importance: Trivalent adjuvanted inactivated influenza vaccine (aIIV3) and trivalent high-dose inactivated influenza vaccine (HD-IIV3) are US-licensed for adults aged 65 years and older. Data are needed on the comparative safety, reactogenicity, and health-related quality of life (HRQOL) effects of these vaccines. Objective: To compare safety, reactogenicity, and changes in HRQOL scores after aIIV3 vs HD-IIV3. Design, Setting, and Participants: This randomized blinded clinical trial was a multicenter US study conducted during the 2017 to 2018 and 2018 to 2019 influenza seasons. Among 778 community-dwelling adults aged at least 65 years and assessed for eligibility, 13 were ineligible and 8 withdrew before randomization. Statistical analysis was performed from August 2019 to August 2020. Interventions: Intramuscular administration of aIIV3 or HD-IIV3 after age-stratification (65-79 years; ≥80 years) and randomization. Main Outcomes and Measures: Proportions of participants with moderate-to-severe injection-site pain and 14 other solicited reactions during days 1 to 8, using a noninferiority test (5% noninferiority margin), and serious adverse events (SAE) and adverse events of clinical interest (AECI), including new-onset immune-mediated conditions, during days 1 to 43. Changes in HRQOL scores before and after vaccination (days 1, 3) were also compared between study groups. Results: A total of 757 adults were randomized, 378 to receive aIIV3 and 379 to receive HD-IIV3. Of these participants, there were 420 women (55%) and 589 White individuals (78%) with a median (range) age of 72 (65-97) years. The proportion reporting moderate-to-severe injection-site pain, limiting or preventing activity, after aIIV3 (12 participants [3.2%]) (primary outcome) was noninferior compared with HD-IIV3 (22 participants [5.8%]) (difference -2.7%; 95% CI, -5.8 to 0.4). Ten reactions met noninferiority criteria for aIIV3; 4 (moderate-to-severe injection-site tenderness, arthralgia, fatigue, malaise) did not. It was inconclusive whether these 4 reactions occurred in higher proportions of participants after aIIV3. No participant sought medical care for a vaccine reaction. No AECI was observed. Nine participants had at least SAE after aIIV3 (2.4%; 95% CI,1.1% to 4.5%); 3 had at least 1 SAE after HD-IIV3 (0.8%; 95% CI, 0.2% to 2.2%). No SAE was associated with vaccination. Changes in prevaccination and postvaccination HRQOL scores were not clinically meaningful and not different between the groups. Conclusions and Relevance: Overall safety and HRQOL findings were similar after aIIV3 and HD-IIV3, and consistent with prelicensure data. From a safety standpoint, this study's results support using either vaccine to prevent influenza in older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT03183908.

Promotion of Physical Activity in Older People Using mHealth and eHealth Technologies: Rapid Review of Reviews.

BACKGROUND: Older people are at increased risk of adverse health events because of reduced physical activity. There is concern that activity levels are further reduced in the context of the COVID-19 pandemic, as many older people are practicing physical and social distancing to minimize transmission. Mobile health (mHealth) and eHealth technologies may offer a means by which older people can engage in physical activity while physically distancing. OBJECTIVE: The objective of this study was to assess the evidence for mHealth or eHealth technology in the promotion of physical activity among older people aged 50 years or older. METHODS: We conducted a rapid review of reviews using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched for systematic reviews published in the English language in 3 electronic databases: MEDLINE, CINAHL Plus, and Scopus. Two reviewers used predefined inclusion criteria to select relevant reviews and extracted data on review characteristics and intervention effectiveness. Two independent raters assessed review quality using the AMSTAR-2 tool. RESULTS: Titles and abstracts (n=472) were screened, and 14 full-text reviews were assessed for eligibility. Initially, we included 5 reviews but excluded 1 from the narrative as it was judged to be of critically low quality. Three reviews concluded that mHealth or eHealth interventions were effective in increasing physical activity. One review found that the evidence was inconclusive. CONCLUSIONS: There is low to moderate evidence that interventions delivered via mHealth or eHealth approaches may be effective in increasing physical activity in older adults in the short term. Components of successful interventions include self-monitoring, incorporation of theory and behavior change techniques, and social and professional support.