Holistic frailty prevention: The promise of movement-based mind-body therapies.

Aging is characterized by fundamental cellular and molecular hallmarks that result in physiologic decline of most body systems. This may culminate in frailty, a state of decreased reserve. Because frailty is a state of multisystem dysregulation, multimodal interventions may be necessary to mitigate and prevent progression rather than interventions targeting a single system. Movement-based mind-body therapies, such as tai chi and yoga, are promising multimodal strategies for frailty prevention and treatment given their inherent multicomponent nature. In this review, we summarize the links between hallmarks of aging and frailty and how tai chi and yoga may impact these hallmarks. We review trial evidence for the impact of tai chi and yoga on frailty in older populations and discuss opportunities for future research.

Clinical Effectiveness of Cognitively Enhanced Tai Ji Quan Training on Global Cognition and Dual-Task Performance During Walking in Older Adults With Mild Cognitive Impairment or Self-Reported Memory Concerns : A Randomized Controlled Trial.

BACKGROUND: Mild cognitive impairment (MCI) negatively impacts cognition and dual-task abilities. A physical-cognitive integrated treatment approach could mitigate this risk for dementia. OBJECTIVE: To compare the effectiveness of cognitively enhanced tai ji quan versus standard tai ji quan or stretching exercise in improving global cognition and reducing dual-task walking costs in older adults with MCI or self-reported memory concerns. DESIGN: 3-group, randomized (1:1:1), superiority trial. (ClinicalTrials.gov: NCT04070703). SETTING: Community residential homes. PARTICIPANTS: 318 older adults with self-reported memory decline or concern and a Clinical Dementia Rating (CDR) global score of 0.5 or lower at baseline. INTERVENTION: Cognitively enhanced tai ji quan (n = 105), standard tai ji quan (n = 107), or stretching (n = 106). All groups exercised at home via real-time videoconferencing, 1 hour semiweekly for 24 weeks. MEASUREMENTS: The co-primary endpoints were change in Montreal Cognitive Assessment (MoCA; range, 0 to 30) and dual-task walking costs (difference between single- and dual-task gait speed, expressed in percentage) from baseline to 24 weeks. Secondary outcomes included CDR-Sum of Boxes (CDR-SB), Trail Making Test B, Digit Span Backward (DSB), and physical performance tests. Outcomes were assessed at 16, 24 (primary endpoint), and 48 weeks (6 months after intervention). RESULTS: A total of 304 participants (96%) completed the 24-week assessment. Cognitively enhanced tai ji quan outperformed standard tai ji quan and stretching with a greater improvement in MoCA score (mean difference, 1.5 points [98.75% CI, 0.7 to 2.2 points] and 2.8 points [CI, 2.1 to 3.6 points], respectively) and in dual-task walking (mean difference, 9.9% [CI, 2.8% to 16.6%] and 22% [CI, 13% to 31%], respectively). The intervention effects persisted at 48-week follow-up. LIMITATION: There was no nonexercise control group; participants had subjective or mild cognitive impairment. CONCLUSION: Among community-dwelling older adults with MCI, cognitively enriched tai ji quan therapy was superior to standard tai ji quan and stretching exercise in improving global cognition and reducing dual-task gait interference, with outcomes sustained at 48 weeks. PRIMARY FUNDING SOURCE: National Institute on Aging.

Can strength training or tai ji quan training reduce frailty in postmenopausal women treated with chemotherapy? A secondary data analysis of the GET FIT trial.

Purpose: To determine whether strength training or tai ji quan can reduce frailty in older, postmenopausal women treated with chemotherapy for cancer. Methods: We conducted a secondary data analysis from a 3-arm, single-blind, randomized controlled trial where older (50+ years), postmenopausal women cancer survivors were randomized to supervised group exercise programs: tai ji quan, strength training, or stretching control for 6 months. We assessed frailty using a 4-criteria model consisting of weakness, fatigue, inactivity, and slowness. Using logistic regression, we determined whether the frailty phenotype (pre-frailty or frailty) decreased post-intervention, how many and which frailty criteria decreased, and what characteristics identified women most likely to reduce frailty. Results: Data from 386 women who completed baseline and 6-month testing were used (mean age of 62.0 ± 6.4 years). The odds of improving overall frailty phenotype over 6 months was significantly higher in the strength training group compared to controls (OR [95%CI]: 1.86 [1.09, 3.17]), but not for for tai ji quan (1.44 [0.84, 2.50]). Both strength training (OR 1.99 [1.10, 3.65]) and tai ji quan (OR 2.10 [1.16, 3.84]) led to significantly higher odds of reducing ≥1 frailty criterion compared to controls. Strength training led to a three-fold reduction in inactivity (p <0.01), and tai ji quan to a two-fold reduction in fatigue (p=0.08) versus control. Higher baseline BMI, comorbidity score, and frailty status characterized women more likely to reduce frailty than other women. Conclusions: Strength training appears superior to tai ji quan and stretching with respect to reducing overall frailty phenotype among postmenopausal women treated with chemotherapy for cancer, but tai ji quan favorably impacted the number of frailty criteria. Implications for Cancer Survivors: Supervised, group exercise training that emphasizes strength training and/or tai ji quan may help combat accelerated aging and reduce frailty after cancer treatment.

GET FIT: A Randomized Clinical Trial of Tai Ji Quan Versus Strength Training for Fall Prevention After Chemotherapy in Older, Postmenopausal Women Cancer Survivors.

PURPOSE: To compare the efficacy of tai ji quan versus strength training to prevent falls after chemotherapy in older, postmenopaual women. METHODS: We conducted a three-arm, single-blind, randomized controlled trial where older (50+ years), postmenopausal women cancer survivors participated in one of three supervised group exercise programs (tai ji quan, strength training, or stretching control) twice weekly for 6 months and were followed up 6 months after training stopped. The primary outcome was the incidence of falls. Secondary outcomes included fall-related injuries, leg strength (1 repetition maximum; kg), and balance (sensory organization [equilibrium score] and limits of stability [LOS; %] tests). RESULTS: Four hundred sixty-two women were enrolled (mean age, 62 ± 6.3 years). Retention was 93%, and adherence averaged 72.9%. In primary analysis, there was no difference in the incidence of falls between groups after 6 months of training, nor during 6-month follow-up. A post hoc analysis detected a significantly reduced incidence of fall-related injuries within the tai ji quan group over the first 6 months, dropping from 4.3 falls per 100 person-months (95% CI, 2.9 to 5.6) at baseline to 2.4 falls per person-months (95% CI, 1.2 to 3.5). No significant changes occurred during 6-month follow-up. Over the intervention period, leg strength significantly improved in the strength group and balance (LOS) improved in the tai ji quan group, compared with controls (P < .05). CONCLUSION: We found no significant reduction in falls for tai ji quan or strength training relative to stretching control in postmenopausal women treated with chemotherapy.

Perceptions That Influence Acupuncture Use in Hospice Settings: Results of a State-Wide Survey Study.

Background: Acupuncture is an effective and low-risk therapy for a wide spectrum of medical conditions. In the hospice setting, where comfort is the top priority, acupuncture could play a vital role in reducing symptom burden at the end of life. Objective: This state-wide survey study explored perceived barriers to acupuncture use in the hospice setting from acupuncturist and hospice staff perspectives. Specific barriers addressed included insurance coverage/funding for acupuncture, lack of knowledge of acupuncture as a therapeutic modality, and perceived insufficient evidence base for acupuncture. Materials and Methods: Acupuncturists and hospice staff in Oregon were recruited by e-mail and/or telephone to complete their survey. Results: Among acupuncturists, a response rate of 50% was obtained. The response rate of hospice staff could not be obtained. There were a total of 270 providers and hospice staff (102 acupuncturists, 16 hospice doctors, 14 hospice directors, 93 hospice nurses, 30 hospice social workers, and 15 hospice chaplains). The majority of acupuncturists (76% and 89%, respectively) and hospice staff (59% and 82%, respectively) strongly agreed or somewhat agreed that insurance coverage/funding for acupuncture and lack of knowledge of acupuncture as a therapeutic modality are important barriers. With respect to the perceived evidence base for acupuncture, the majority of acupuncturists (91%) and hospice staff (69%) strongly agreed or somewhat agreed that acupuncture can help provide a higher quality of life for hospice patients, although knowledge of specific conditions amenable to acupuncture among acupuncturists and hospice staff varied. Conclusions: From the acupuncturist and hospice staff perspectives, insurance coverage/funding for acupuncture, lack of knowledge of acupuncture as a therapeutic modality, and perceived insufficient evidence base for acupuncture are primary barriers to the use of acupuncture in hospice care. Increased awareness/education about acupuncture in the hospice setting, as well as improved funding structures, is critical.

Effectiveness of Tai Ji Quan vs Multimodal and Stretching Exercise Interventions for Reducing Injurious Falls in Older Adults at High Risk of Falling: Follow-up Analysis of a Randomized Clinical Trial.

Importance: Exercise has been shown to reduce injurious falls in older adults. Evidence, however, is lacking regarding the types of intervention that are most effective in preventing injurious falls among older adults at high risk of falling. Objective: To determine the longer-term effectiveness of therapeutic tai ji quan intervention vs multimodal exercise and stretching exercise in decreasing injurious falls among older adults at high risk of falling. Design, Setting, and Participants: This trial involves a prespecified analysis with the data analyzed by intent-to-treat. Follow-up analysis of a single-blind randomized trial conducted in community settings of 7 urban and suburban cities in Oregon from February 20, 2015, to September 15, 2018, compared a therapeutic tai ji quan intervention with multimodal exercise and stretching exercise. Eligible participants were community-dwelling adults aged at least 70 years who were considered by a clinician to be at high risk of falling because they had fallen during the preceding year or who had impaired mobility with scores higher than 13.5 seconds on the Timed Up & Go test. Participants were randomized to 1 of the 3 interventions and were assessed monthly after randomization for 12 months, encompassing a 6-month active intervention phase and a 6-month after intervention follow-up phase. Interventions: The 3 group-based interventions were therapeutic tai ji quan (Tai Ji Quan: Moving for Better Balance [TJQMBB]), multimodal exercise, and stretching exercise, each implemented twice weekly in 60-minute sessions for 24 weeks. Main Outcomes and Measures: Primary outcomes were the incidence of moderate and serious injurious falls at 12 months, measured as incidence rate ratios (IRRs). Results: Of the 1147 persons screened, 670 (mean [SD] age, 77.7 [5.6] years; 436 women [65.1%]) were randomly assigned to 1 of 3 intervention groups: 224 persons in TJQMBB, 223 in multimodal exercise, and 223 in stretching exercise. At 12 months, the unadjusted IRR for moderate injurious falls was lower in the TJQMBB (IRR, 0.51; 95% CI, 0.35-0.74; P < .001) and multimodal exercise (IRR, 0.62; 95% CI, 0.42-0.89; P = .01) groups compared with the stretching exercise group. There was no difference between TJQMBB and multimodal exercise groups (IRR, 0.85; 95% CI, 0.58-1.25; P = .42). Both TJQMBB and multimodal exercise significantly reduced serious injurious falls (TJQMBB: IRR, 0.25 [95% CI, 0.13-0.48; P < .001]; multimodal: IRR, 0.56 [95% CI, 0.33-0.94; P = .03]) compared with stretching exercise. Use of TJQMBB was more effective than multimodal exercise (IRR, 0.47; 95% CI, 0.24-0.92; P = .03) in reducing serious injurious falls. Conclusions and Relevance: For preventing injurious falls, including those that resulted in medical treatment, TJQMBB intervention was found to be superior to multimodal and stretching exercises for older adults at high risk of falling. The findings appear to strengthen the clinical use of TJQMBB as a single exercise intervention to prevent injurious falls in this population. Trial Registration: ClinicalTrials.gov Identifier: NCT02287740.

Cost-Effectiveness of a Therapeutic Tai Ji Quan Fall Prevention Intervention for Older Adults at High Risk of Falling.

BACKGROUND: Data on the cost-effectiveness of proven fall prevention exercise interventions are limited. We aimed to establish the cost-effectiveness of Tai Ji Quan: Moving for Better Balance (TJQMBB) compared with a conventional exercise intervention for older adults at high risk of falling. METHODS: We conducted a trial-based cost-effectiveness analysis involving 670 older adults who had a history of falling or impaired mobility. Participants received one of three interventions-TJQMBB, multimodal exercise, or stretching exercise (control)-each of which was implemented twice weekly for 24 weeks. The primary cost-effectiveness measure was the incremental cost per additional fall prevented, comparing TJQMBB and multimodal exercise to Stretching and TJQMBB to multimodal exercise, with a secondary measure of incremental cost per additional quality-adjusted life-year (QALY) gained. The intervention was conducted between February 2015 and January 2018, and cost-effectiveness was estimated from a health care system perspective over a 6-month time horizon. RESULTS: The total cost to deliver the TJQMBB intervention was $202,949 (an average of $906 per participant); for multimodal exercise, it was $223,849 ($1,004 per participant); and for Stretching, it was $210,468 ($903 per participant). Incremental cost-effectiveness ratios showed that the multimodal exercise was cost-effective ($850 per additional fall prevented; $27,614 per additional QALY gained) relative to Stretching; however, TJQMBB was the most economically dominant strategy (ie, having lower cost and being clinically more efficacious) compared with multimodal and stretching exercises with regard to cost per additional fall prevented and per additional QALY gained. TJQMBB had a 100% probability of being cost-effective, relative to Stretching, at a threshold of $500 per each additional fall prevented and $10,000 per additional QALY gained. Sensitivity analyses showed the robustness of the results when extreme cases, medical costs only, and missing data were considered. CONCLUSIONS: Among community-dwelling older adults at high risk for falls, TJQMBB is a cost-effective means of reducing falls compared with conventional exercise approaches. TRIAL REGISTRATION: Clinicaltrials.gov (NCT02287740).

Effectiveness of a Therapeutic Tai Ji Quan Intervention vs a Multimodal Exercise Intervention to Prevent Falls Among Older Adults at High Risk of Falling: A Randomized Clinical Trial.

Importance: Falls in older adults are a serious public health problem associated with irreversible health consequences and responsible for a substantial economic burden on health care systems. However, identifying optimal choices from among evidence-based fall prevention interventions is challenging as few comparative data for effectiveness are available. Objective: To determine the effectiveness of a therapeutically tailored tai ji quan intervention, Tai Ji Quan: Moving for Better Balance (TJQMBB), developed on the classic concept of tai ji (also known as tai chi), and a multimodal exercise (MME) program relative to stretching exercise in reducing falls among older adults at high risk of falling. Design, Setting, and Participants: A single-blind, 3-arm, parallel design, randomized clinical trial (February 20, 2015, to January 30, 2018), in 7 urban and suburban cities in Oregon. From 1147 community-dwelling adults 70 years or older screened for eligibility, 670 who had fallen in the preceding year or had impaired mobility consented and were enrolled. All analyses used intention-to-treat assignment. Interventions: One of 3 exercise interventions: two 60-minute classes weekly for 24 weeks of TJQMBB, entailing modified forms and therapeutic movement exercises; MME, integrating balance, aerobics, strength, and flexibility activities; or stretching exercises. Main Outcomes and Measures: The primary measure at 6 months was incidence of falls. Results: Among 670 participants randomized, mean (SD) age was 77.7 (5.6) years, 436 (65%) were women, 617 (92.1%) were white, 31 (4.6%) were African American. During the trial, there were 152 falls (85 individuals) in the TJQMBB group, 218 (112 individuals) in the MME group, and 363 (127 individuals) in the stretching exercise group. At 6 months, the incidence rate ratio (IRR) was significantly lower in the TJQMBB (IRR, 0.42; 95% CI, 0.31-0.56; P < .001) and MME groups (IRR, 0.60; 95% CI, 0.45-0.80; P = .001) compared with the stretching group. Falls were reduced by 31% for the TJQMBB group compared with the MME group (IRR, 0.69; 95% CI, 0.52-0.94; P = .01). Conclusions and Relevance: Among community-dwelling older adults at high risk for falls, a therapeutically tailored tai ji quan balance training intervention was more effective than conventional exercise approaches for reducing the incidence of falls. Trial Registration: ClinicalTrials.gov identifier: NCT02287740.

An Interprofessional Approach to Reducing the Risk of Falls Through Enhanced Collaborative Practice.

Falls are the leading cause of accidental deaths in older adults and are a growing public health concern. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) published guidelines for falls screening and risk reduction, yet few primary care providers report following any guidelines for falls prevention. This article describes a project that engaged an interprofessional teaching team to support interprofessional clinical teams to reduce fall risk in older adults by implementing the AGS/BGS guidelines. Twenty-five interprofessional clinical teams with representatives from medicine, nursing, pharmacy, and social work were recruited from ambulatory, long-term care, hospital, and home health settings for a structured intervention: a 4-hour training workshop plus coaching for implementation for 1 year. The workshop focused on evidence-based strategies to decrease the risk of falls, including screening for falls; assessing gait, balance, orthostatic blood pressure, and other medical conditions; exercise including tai chi; vitamin D supplementation; medication review and reduction; and environmental assessment. Quantitative and qualitative data were collected using chart reviews, coaching plans and field notes, and postintervention structured interviews of participants. Site visits and coaching field notes confirmed uptake of the strategies. Chart reviews showed significant improvement in adoption of all falls prevention strategies except vitamin D supplementation. Long-term care facilities were more likely to address environmental concerns and add tai chi classes, and ambulatory settings were more likely to initiate falls screening. The intervention demonstrated that interprofessional practice change to target falls prevention can be incorporated into primary care and long-term care settings.

A randomized controlled trial of patient-reported outcomes with tai chi exercise in Parkinson's disease.

A previous randomized, controlled trial of tai chi showed improvements in objectively measured balance and other motor-related outcomes in patients with Parkinson's disease. This study evaluated whether patient-reported outcomes could be improved through exercise interventions and whether improvements were associated with clinical outcomes and exercise adherence. In a secondary analysis of the tai chi trial, patient-reported and clinical outcomes and exercise adherence measures were compared between tai chi and resistance training and between tai chi and stretching exercise. Patient-reported outcome measures were perceptions of health-related benefits resulting from participation, assessed by the Parkinson's Disease Questionnaire (PDQ-8) and Vitality Plus Scale (VPS). Clinical outcome measures included motor symptoms, assessed by a modified Unified Parkinson's Disease Rating Scale-Motor Examination (UPDRS-ME) and a 50-foot speed walk. Information on continuing exercise after the structured interventions were terminated was obtained at a 3-month postintervention follow-up. Tai chi participants reported significantly better improvement in the PDQ-8 (-5.77 points, P = 0.014) than did resistance training participants and in PDQ-8 (-9.56 points, P < 0.001) and VPS (2.80 points, P = 0.003) than did stretching participants. For tai chi, patient-reported improvement in the PDQ-8 and VPS was significantly correlated with their clinical outcomes of UPDRS-ME and a 50-foot walk, but these correlations were not statistically different from those shown for resistance training or stretching. However, patient-reported outcomes from tai chi training were associated with greater probability of continued exercise behavior than were either clinical outcomes or patient-reported outcomes from resistance training or stretching. Tai chi improved patient-reported perceptions of health-related benefits, which were found to be associated with a greater probability of exercise adherence. The findings indicate the potential of patient perceptions to drive exercise behavior after structured exercise programs are completed and the value of strengthening such perceptions in any behavioral intervention.

Tai chi and postural stability in patients with Parkinson's disease.

BACKGROUND: Patients with Parkinson's disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling. Although exercise is routinely encouraged by health care providers, few programs have been proven effective. METHODS: We conducted a randomized, controlled trial to determine whether a tailored tai chi program could improve postural control in patients with idiopathic Parkinson's disease. We randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale (which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three groups: tai chi, resistance training, or stretching. The patients participated in 60-minute exercise sessions twice weekly for 24 weeks. The primary outcomes were changes from baseline in the limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary outcomes included measures of gait and strength, scores on functional-reach and timed up-and-go tests, motor scores on the Unified Parkinson's Disease Rating Scale, and number of falls. RESULTS: The tai chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points; 95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI, 3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. No serious adverse events were observed. CONCLUSIONS: Tai chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinson's disease, with additional benefits of improved functional capacity and reduced falls. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00611481.).

Enhancing the effectiveness of One-Minute Preceptor faculty development workshops.

BACKGROUND: The One Minute Preceptor (OMP) faculty development workshop is aimed at improving outpatient preceptors' abilities to teach in ambulatory settings. Practice applying the 5 microskills is central to learning the OMP, yet participants frequently avoid the role-playing portion of the standard workshop. Task complexity may result in significant cognitive burden while learning these new teaching skills. DESCRIPTION: The development of highly scripted case scenarios and standardized learners (SLs) to role-play authentic teaching situations are aimed at reducing task complexity. We describe case development, SL training, and application of these enhancements in 5 OMP workshops. EVALUATION: Qualitative assessments and workshop participant evaluations showed improved role-playing participation and satisfaction with the authenticity of the training sessions. CONCLUSION: The introduction of highly scripted cases and SLs appear to effectively help participants overcome dissatisfaction with role-playing and provide increasingly challenging yet authentic clinical teaching scenarios for skills practice. We recommend further research using objective measures.

Tai Chi and fall reductions in older adults: a randomized controlled trial.

BACKGROUND: The authors' objective was to evaluate the efficacy of a 6-month Tai Chi intervention for decreasing the number of falls and the risk for falling in older persons. METHODS: This randomized controlled trial involved a sample of 256 physically inactive, community-dwelling adults aged 70 to 92 (mean age, 77.48 years; standard deviation, 4.95 years) who were recruited through a patient database in Portland, Oregon. Participants were randomized to participate in a three-times-per-week Tai Chi group or to a stretching control group for 6 months. The primary outcome measure was the number of falls; the secondary outcome measures included functional balance (Berg Balance Scale, Dynamic Gait Index, Functional Reach, and single-leg standing), physical performance (50-foot speed walk, Up&Go), and fear of falling, assessed at baseline, 3 months, 6 months (intervention termination), and at a 6-month postintervention follow-up. RESULTS: At the end of the 6-month intervention, significantly fewer falls (n=38 vs 73; p=.007), lower proportions of fallers (28% vs 46%; p=.01), and fewer injurious falls (7% vs 18%; p=.03) were observed in the Tai Chi group compared with the stretching control group. After adjusting for baseline covariates, the risk for multiple falls in the Tai Chi group was 55% lower than that of the stretching control group (risk ratio,.45; 95% confidence interval, 0.30 to 0.70). Compared with the stretching control participants, the Tai Chi participants showed significant improvements (p<.001) in all measures of functional balance, physical performance, and reduced fear of falling. Intervention gains in these measures were maintained at a 6-month postintervention follow-up in the Tai Chi group. CONCLUSIONS: A three-times-per-week, 6-month Tai Chi program is effective in decreasing the number of falls, the risk for falling, and the fear of falling, and it improves functional balance and physical performance in physically inactive persons aged 70 years or older.