Falls and Cognitive Training 2 (FaCT2) study protocol: a randomised controlled trial exploring cognitive training to reduce risk of falls in at-risk older adults.

BACKGROUND: The primary cause of traumatic injury in older adults is fall. Recent reports suggest that cognitive function contributes significantly to fall risk. Therefore, by targeting cognitive function for intervention, we could potentially reduce the incidence of fall and injury. PRIMARY OBJECTIVE: To explore the effectiveness of a 16-week cognitive training (CT) intervention to reduce risk and incidence of fall in community-dwelling older adults at risk for fall. OUTCOMES: Primary outcome is number of falls over a 16-week period (ascertained by fall calendar method). Secondary outcomes include: change fall risk as indicated by improvement in 10 m walk and 90 s balance tests. DESIGN/METHODS: The design is a two-group randomised controlled trial. Eligible participants are older adults (aged 65-85) residing in the community who are at risk for fall based on physical performance testing. Following completion of 1-week run-in phase, participants are randomly allocated (1:2) to either a group that is assigned to attention control or to the group that receives CT intervention for a total of 16 weeks. Participants are followed for an additional 4 weeks after intervention. Mann-Whitney U test and Student's t-test will be used to examine between-group differences using intention-to-treat analyses. DISCUSSION: Limited evidence supports the potential of CT to improve cognition and gait, but no published study has evaluated whether such an intervention would reduce incidence of fall. The present trial is designed to provide initial answers to this question. CT may also improve functioning important in other activities (eg, driving), reducing overall risk of injury in elders. TRIAL REGISTRATION NUMBER: NCT03190460.

Integrating Health Promotion Into Physical Therapy Practice to Improve Brain Health and Prevent Alzheimer Disease.

BACKGROUND AND PURPOSE: Alzheimer disease is the most common cause of dementia, and brain pathology appears years before symptoms are evident. Primary prevention through health promotion can incorporate lifestyle improvement across the lifespan. Risk factor assessment and identifying markers of disease might also trigger preventive measures needed for high-risk individuals and groups. SUMMARY OF KEY POINTS: Many potential risk factors are modifiable through exercise, and may be responsive to early intervention strategies to reduce the downward slope toward disability. Through the use of common clinical tests to identify cognitive and noncognitive functional markers of disease, detection and intervention can occur at earlier stages, including preclinical stages of disease. Physical activity and exercise interventions to address modifiable risk factors and impairments can play a pivotal role in the prevention and delay of functional decline, ultimately reducing the incidence of dementia. This article discusses prevention, prediction, plasticity, and participation in the context of preserving brain health and preventing Alzheimer disease and related dementias in aging adults. RECOMMENDATIONS FOR CLINICAL PRACTICE: Rehabilitation professionals have opportunities to slow disease progression through research, practice, and education initiatives. From a clinical perspective, interventions that target brain health through lifestyle changes and exercise interventions show promise for preventing stroke and associated neurovascular diseases in addition to dementia. Physical therapists are well positioned to integrate primary health promotion into practice for the prevention of dementia and other neurological conditions in older adults.

A Tandem Cycling Program: Feasibility and Physical Performance Outcomes in People With Parkinson Disease.

BACKGROUND AND PURPOSE: Individuals with Parkinson disease (PD) have motor and nonmotor impairments that interfere with exercise participation. The purpose of this study was to examine the feasibility and physical performance outcomes of a community-based indoor tandem cycling program that was designed to facilitate a higher cadence, consistency, and intensity of training. METHODS: Forty-one participants with mild to moderate PD were enrolled. A high-cadence cycling protocol using mechanically augmented (or forced) exercise on a tandem bicycle was adapted for our program. Participants cycled 3 times per week for 10 weeks. Feasibility measures included program retention, attendance, and adverse events, as well as the ability to reach training goals for heart rate (HR) and cadence. Physical performance outcomes included the Berg Balance Scale (BBS), Short Physical Performance Battery (SPPB), Five-Times-Sit-to-Stand (FTSTS) Test, Timed Up and Go (TUG), and gait parameters during usual and fast-paced walking. RESULTS: Program feasibility was demonstrated with a high attendance rate (96%) and retention rate (100%). There were no adverse events. The majority of participants reached their exercise training goals for target HR (87%) and cadence (95%). Statistically significant physical performance improvement (P < 0.05) was observed across domains of gait, balance, and mobility, suggesting a slowing or reversal of functional decline as a result of this cycling program. DISCUSSION AND CONCLUSION: Program feasibility and improved physical performance outcomes were demonstrated in individuals with mild to moderate PD participating in a community-based indoor tandem cycling program.Video Abstract available for more insights from the authors (see supplemental digital content 1, http://links.lww.com/JNPT/A146).

Implementation of Evidence-Based Practice in Long-Term Care: A Scoping Review.

OBJECTIVES: To systematically examine implementation strategies within long-term care (LTC) settings. The goal was to identify elements that contribute to adoption and sustainability of evidence-based practices by facilities and frontline health care staff. DESIGN: Scoping review. SETTING AND PARTICIPANTS: LTC settings, frontline health care staff and facility administration. METHODS: A scoping review of the literature across 3 databases was performed. Two researchers independently assessed literature for inclusion against criteria. The researchers independently extracted data for study characteristics following the Action, Actor, Context, Target, Time (AACTT) framework. The quality of included studies was assessed using the Melnyk and Fineout-Overholt Categorization. RESULTS: Eleven studies examining implementation of a new evidence-based intervention into LTC settings met inclusion requirements. The types of new interventions shared a common classification within the Effective Practice and Organization of Care (EPOC) taxonomy, with all belonging to the Coordination of Care and Management of Care Processes category. All studies had frontline health care staff as the target of implementation strategies. Barriers to implementation included intervention timing in relation to workflow and workload, lack of interest in or skepticism regarding the new intervention, as well as perceptions that the intervention was not within scope or training. Face-to-face communication and asynchronous training were viewed positively, as was having a peer champion available for support. CONCLUSIONS AND IMPLICATIONS: The results from this review highlight the importance of including communication strategies that use face-to-face delivery and peer champion approaches for successful implementation of new evidence-based interventions. Key implementation strategies also included education tailored to an individual's training and experience level.

Centering the person in development of a model of care for people with Parkinson's disease: a qualitative study.

PURPOSE: Obtain the perspectives of people with Parkinson's disease (PwPD) and their care partners (CPs) about their lived experiences with Parkinson's Disease (PD) to characterize a new model of care that meets their biopsychosocial and healthcare needs. METHODS: This phenomenological study included semi-structured focus groups exploring PD diagnosis/care experiences and conceptualizations of an ideal model of care among PwPD and CPs. Data were analyzed via thematic analysis. RESULTS: Twenty-five individuals (PwPD, n = 18; CPs, n = 7) participated across four focus groups. Researchers developed four themes to describe participants' lived experience with, barriers to, and needs for PD care. These themes characterize key hopes for care as: 1) person-centered, 2) coordinated, 3) provides access to education and information, and 4) builds on the benefits of community. CONCLUSIONS: Participants emphasized that, beyond clinical interactions and diagnosis-centered conversations, they wished for holistic healthcare that acknowledged the larger picture of their life with PD. An ideal model of care for PwPD should aim to be person centered, maximize collaboration and coordination across multiple disciplines, provide access to a wide range of information and resources, refer to community centers and support groups, and be designed with ease of navigation in mind.

Health professionals need to inquire about an individual's lived experience and employ strategies that center the person and personalizes their care while also integrating a coordinated interdisciplinary approach.An ideal model of care needs to integrate healthcare professionals as part of a larger care team that includes the person with Parkinson's disease, and facilitates communication and planning with those team membersAn ideal model of care needs to integrate the larger community and seek to refer and build relationships with health professionals, organizations, and non-medical providers that will facilitate holistic care and advocate for people with Parkinson's disease.

Validity of Instrumented 360° Turn Test in Older Adults with Cognitive Impairment.

AIMS: To examine concurrent and construct validity of inertial sensor 360°turn measures in relation with motion capture and mobility assessments in cognitively impaired older adults. METHODS: Data was collected in 31 participants, mean age 85.2 (SD 5.2), during clockwise (CW) and counter clockwise (CCW) 360° turns using (1) APDM body-worn inertial sensors and (2) Qualisys 8-camera laboratory-based motion capture. RESULTS: Absolute agreement between inertial sensor and motion capture measures was excellent for turn duration and turn peak velocity (ICC = 0.96-0.98). Strong to moderate correlations were present between inertial sensor turn measures and performance on the Timed Up and Go, Short Physical Performance Battery and 90-s Balance Test. ROC curve analysis of CCW 360° turn duration and turn peak velocity distinguished higher risk versus lower risk for mobility disability. CONCLUSIONS: Inertial sensor 360° turn measures demonstrated concurrent and construct validity in relation to motion capture and mobility assessments.

Translating an Evidence-based Multicomponent Intervention for Older Adults With Dementia and Caregivers.

BACKGROUND AND OBJECTIVES: Effective community-based programs to maintain health and well-being of adults with dementia are needed. This article describes the translation, implementation, and effectiveness of a multicomponent exercise plus behavioral/psychosocial intervention (Reducing Disability in Alzheimer's Disease-NorthWest [RDAD-NW]) conducted by staff in regional Area Agencies on Aging (AAAs). RESEARCH DESIGN AND METHODS: Staggered multiple baseline design was used; 10 AAAs, 20 case managers, and 255 community-residing persons with dementia (PWDs), and family caregivers were enrolled. RDAD-NW was conducted in-home over 6 weeks with aerobic/endurance, strength, and balance/flexibility exercises, dementia education, training to increase pleasant events, and activator-behavior-consequence problem-solving approach. Outcomes included case manager treatment fidelity, and caregiver/PWD physical activity, restricted activity days, physical functioning, quality of life, and affect. RESULTS: RDAD-NW was successfully translated and implemented by AAA agency staff through their usual service provision mechanisms. Staff responded positively and delivered the program with a high degree of fidelity. Caregiver/PWD dyads also responded favorably engaging in both exercise and behavioral/psychosocial portions of the program. A total of 207 dyads (81%) completed the intervention and 140 (55%) completed the 13-month follow-up. PWD physical activity increased significantly pre- to posttreatment (p < .001, ES = .54), and 13 months (p < .01, ES = .21). Quality of life of PWD increased significantly pre- to posttreatment (p < .001, ES = .29); caregiver depression improved pre- to posttreatment (p = .01, ES = -.18). DISCUSSION AND IMPLICATIONS: RDAD-NW was successfully translated and implemented by AAA case managers and resulted in increased physical activity and improved behavioral and emotional outcomes of caregiver/PWDs. Results support continued dissemination and implementation of RDAD-NW. CLINICAL TRIALS REGISTRATION: NCT01708304.

A Scoping Review of Physical Performance Outcome Measures Used in Exercise Interventions for Older Adults With Alzheimer Disease and Related Dementias.

BACKGROUND AND PURPOSE: There is growing evidence that exercise interventions can mitigate functional decline and reduce fall risk in older adults with Alzheimer disease and related dementias (ADRD). Although physical performance outcome measures have been successfully used in older adults without cognitive impairment, additional research is needed regarding their use with individuals who have ADRD, and who may have difficulty following instructions regarding performance of these measures. The purpose of this scoping review was to identify commonly used physical performance outcome measures, for exercise interventions, that are responsive and reliable in older adults with ADRD. Ultimately, we aimed to provide recommendations regarding the use of outcome measures for individuals with ADRD across several domains of physical performance. METHODS: A scoping review was conducted to broadly assess physical performance outcome measures used in exercise interventions for older adults with ADRD. Exercise intervention studies that included at least 1 measure of physical performance were included. All physical performance outcome measures were abstracted, coded, and categorized into 5 domains of physical performance: fitness, functional mobility, gait, balance, and strength. Criteria for recommendations were based on (1) the frequency of use, (2) responsiveness, and (3) reliability. Frequency was determined by the number of studies that used the outcome measure per physical performance domain. Responsiveness was assessed via calculated effect size of the outcome measures across studies within physical performance domains. Reliability was evaluated via published studies of psychometric properties. RESULTS AND DISCUSSION: A total of 20 physical performance outcome measures were extracted from 48 articles that met study inclusion criteria. The most frequently used outcome measures were the 6-minute walk test, Timed Up and Go, repeated chair stand tests, short-distance gait speed, the Berg Balance Scale, and isometric strength measures. These outcome measures demonstrated a small, medium, or large effect in at least 50% of the exercise intervention studies. Good to excellent reliability was reported in samples of older adults with mild to moderate dementia. Fitness, functional mobility, gait, balance, and strength represent important domains of physical performance for older adults. The 6-minute walk test, Timed Up and Go, repeated chair stand tests, short-distance gait speed, Berg Balance Scale, and isometric strength are recommended as commonly used and reliable physical performance outcome measures for exercise interventions in older adults with mild to moderate ADRD. Further research is needed on optimal measures for individuals with severe ADRD. CONCLUSIONS: The results of this review will aid clinicians and researchers in selecting reliable measures to evaluate physical performance outcomes in response to exercise interventions in older adults with ADRD.

People Living With HIV: Implications for Rehabilitation Nurses.

PURPOSE: The aim of this study was to present a brief overview of challenges faced by people living with HIV (PLHIV) as they age, to discuss the relevance of HIV to rehabilitation nurses, and to provide evidence-based recommendations for rehabilitation professionals working with PLHIV. DESIGN: Current issues article. METHODS: Literature review related to age-related comorbidities in PLHIV with implications for rehabilitation nurses. FINDINGS: Rehabilitation nurses must be prepared to address issues specific to people living with HIV including sensitivity and privacy regarding HIV status and increased risk of delayed or complicated healing. Rehabilitation nurses should also promote self-management behavior to optimize health in people living with HIV. CONCLUSIONS: Understanding unique characteristics of PLHIV as well as applying focused assessment and tailored interventions in PLHIV will give rehabilitation nurses the tools to successfully guide PLHIV through the rehabilitation process and optimize clinical outcomes. CLINICAL RELEVANCE: As people with HIV age and experience acute and chronic comorbidities, they will require the clinical expertise of rehabilitation nurses in the process to successfully transition through acute and subacute health care and regain function.

Concurrent Validity of Postural Sway Measures in Older Adults with Cognitive Impairment.

AIMS: To examine concurrent validity of inertial sensor (APDM ISway) versus force plate center of pressure (COP) measures of postural sway in cognitively impaired older adults. METHODS: Participants, mean age 85.6 (SD 4.8), were tested in 4 static standing conditions: (1) eyes open/normal base, (2) eyes open/narrow base, (3) eyes closed/normal base, and (4) eyes closed/narrow base. ISway and COP measures were collected. RESULTS: Strong correlations between ISway trunk sway smoothness [ISway JERK, (m 2 /s 5 )] and COP path length (r = 0.67-0.85) and COP mean velocity (r = 0.77-0.87); also ISway total sway acceleration path length/trail duration [ISway PATH, (m2/s2)] and COP path length (r = 0.77-0.87) and COP mean velocity (r = 0.77-0.91). Increased sway was detected in narrow versus normal base and eyes closed versus open conditions (P = .001). CONCLUSIONS: APDM ISway demonstrated concurrent validity to force-plate COP and changes in postural sway were detected between conditions.

Limbic and Basal Ganglia Neuroanatomical Correlates of Gait and Executive Function: Older Adults With Mild Cognitive Impairment and Intact Cognition.

OBJECTIVE: This study aimed to examine differences in spatiotemporal gait parameters between older adults with amnestic mild cognitive impairment and normal cognition and to examine limbic and basal ganglia neural correlates of gait and executive function in older adults without dementia. DESIGN: This was a cross-sectional study of 46 community-dwelling older adults, ages 70-95 yrs, with amnestic mild cognitive impairment (n = 23) and normal cognition (n = 23). Structural magnetic resonance imaging was used to attain volumetric measures of limbic and basal ganglia structures. Quantitative motion analysis was used to measure spatiotemporal parameters of gait. The Trail Making Test was used to assess executive function. RESULTS: During fast-paced walking, older adults with amnestic mild cognitive impairment demonstrated significantly slower gait speed and shorter stride length compared with older adults with normal cognition. Stride length was positively correlated with hippocampal, anterior cingulate, and nucleus accumbens volumes (P < 0.05). Executive function was positively correlated with hippocampal, anterior cingulate, and posterior cingulate volumes (P < 0.05). CONCLUSIONS: Compared with older adults with normal cognition, those with amnestic mild cognitive impairment demonstrated slower gait speed and shorter stride length, during fast-paced walking, and lower executive function. Hippocampal and anterior cingulate volumes demonstrated moderate positive correlation with both gait and executive function, after adjusting for age. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) discuss gait performance and cognitive function in older adults with amnestic mild cognitive impairment versus normal cognition, (2) discuss neurocorrelates of gait and executive function in older adults without dementia, and (3) recognize the importance of assessing gait speed and cognitive function in the clinical management of older adults at risk for dementia. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Posterior Cingulate Lactate as a Metabolic Biomarker in Amnestic Mild Cognitive Impairment.

Mitochondrial dysfunction represents a central factor within the pathogenesis of the Alzheimer's disease (AD) spectrum. We hypothesized that in vivo measurements of lactate (lac), a by-product of glycolysis, would correlate with functional impairment and measures of brain health in a cohort of 15 amnestic mild cognitive impairment (aMCI) individuals. Lac was quantified from the precuneus/posterior cingulate (PPC) using 2-dimensional J-resolved magnetic resonance spectroscopy (MRS). Additionally, standard behavioral and imaging markers of aMCI disease progression were acquired. PPC lac was negatively correlated with performance on the Wechsler logical memory tests and on the minimental state examination even after accounting for gray matter, cerebral spinal fluid volume, and age. No such relationships were observed between lac and performance on nonmemory tests. Significant negative relationships were also noted between PPC lac and hippocampal volume and PPC functional connectivity. Together, these results reveal that aMCI individuals with a greater disease progression have increased concentrations of PPC lac. Because lac is upregulated as a compensatory response to mitochondrial impairment, we propose that J-resolved MRS of lac is a noninvasive, surrogate biomarker of impaired metabolic function and would provide a useful means of tracking mitochondrial function during therapeutic trials targeting brain metabolism.

Physical exercise and cognitive performance in the elderly: current perspectives.

In an aging population with increasing incidence of dementia and cognitive impairment, strategies are needed to slow age-related decline and reduce disease-related cognitive impairment in older adults. Physical exercise that targets modifiable risk factors and neuroprotective mechanisms may reduce declines in cognitive performance attributed to the normal aging process and protect against changes related to neurodegenerative diseases such as Alzheimer's disease and other types of dementia. In this review we summarize the role of exercise in neuroprotection and cognitive performance, and provide information related to implementation of physical exercise programs for older adults. Evidence from both animal and human studies supports the role of physical exercise in modifying metabolic, structural, and functional dimensions of the brain and preserving cognitive performance in older adults. The results of observational studies support a dose-dependent neuroprotective relationship between physical exercise and cognitive performance in older adults. Although some clinical trials of exercise interventions demonstrate positive effects of exercise on cognitive performance, other trials show minimal to no effect. Although further research is needed, physical exercise interventions aimed at improving brain health through neuroprotective mechanisms show promise for preserving cognitive performance. Exercise programs that are structured, individualized, higher intensity, longer duration, and multicomponent show promise for preserving cognitive performance in older adults.

Functional mobility limitations and falls in assisted living residents with dementia: physical performance assessment and quantitative gait analysis.

BACKGROUND AND PURPOSE: The prevalence of functional mobility limitations and falls is higher in people with dementia compared with cognitively healthy older adults, and both are associated with gait and motor impairments. The aims of this study were to examine concurrent validity of physical performance assessments and spatiotemporal gait measures in older adults with advanced dementia and to prospectively examine their relationship to functional mobility limitations and falls over a 4-month period. METHODS: Thirty-one older adults living in dementia-specific assisted living residences participated. Correlations were examined between a modified Berg Balance Scale (mod-Berg), the Short Physical Performance Battery (SPPB), and spatiotemporal gait measures using the GAITRite Walkway system. Over 4-months, functional mobility limitations were rated, and falls were recorded by nursing supervisors. Differences in functional mobility limitations and falls were examined in relation to baseline balance and gait measures. RESULTS: Partial correlations between spatiotemporal gait measures and the mod-Berg as well as the SPPB were statistically significant (P < .05) after adjusting for age and Mini-Mental State Examination scores. Participants with low functional mobility ratings had significantly lower scores on the mod-Berg (P ≤ .001) and SPPB (P ≤ .001). They also demonstrated slower gait speed, lower cadence, higher stride time variability, and a greater percentage of gait cycle in double support (P ≤ .01). Participants with at least 1 fall, compared with those who did not fall, had lower scores on the mod-Berg (P = .02), lower cadence (P = .048), and greater stride length variability (P = .035). DISCUSSION: The mod-Berg and SPPB were strongly correlated with reliable gait measures associated with instability and increased fall risk. The modified Berg Balance Scale demonstrates potential as a predictor of falls in older adults living in dementia-specific assisted living. CONCLUSION: The results of this study provide support for the application of brief physical performance assessments by physical therapists to identify functional mobility limitations and fall risk in older adults with advanced dementia.

Development of evidence-based exercise recommendations for older HIV-infected patients.

Advances in antiretroviral therapy (ART) have decreased HIV-related morbidity and mortality and contributed to rapidly increasing numbers of older people living with HIV. Successful management of ART-related side effects (metabolic syndrome) and age-related comorbidities (frailty) are major challenges for patients and providers. Exercise has proven beneficial for younger HIV-infected patients, but we know little about which exercise regimens to recommend to the elderly. Our goal was to develop age-appropriate, evidence-based exercise recommendations for older HIV-infected adults (age > 50). We reviewed randomized controlled trials on the effects of physical exercise for: (a) HIV-infected young adults, (b) frail older adults, and (c) elderly individuals with metabolic syndrome. We recommend a combination of endurance and resistance exercises 3 times per week for at least 6 weeks to improve cardiovascular, metabolic, and muscle function. Further research is warranted to study the benefits and risks of physical exercise in older HIV-infected patients.

Associations between physical performance and executive function in older adults with mild cognitive impairment: gait speed and the timed "up & go" test.

BACKGROUND: Older adults with amnestic mild cognitive impairment (aMCI) are at higher risk for developing Alzheimer disease. Physical performance decline on gait and mobility tasks in conjunction with executive dysfunction has implications for accelerated functional decline, disability, and institutionalization in sedentary older adults with aMCI. OBJECTIVES: The purpose of this study was to examine whether performance on 2 tests commonly used by physical therapists (usual gait speed and Timed "Up & Go" Test [TUG]) are associated with performance on 2 neuropsychological tests of executive function (Trail Making Test, part B [TMT-B], and Stroop-Interference, calculated from the Stroop Word Color Test) in sedentary older adults with aMCI. DESIGN: The study was a cross-sectional analysis of 201 sedentary older adults with memory impairment participating in a longitudinal intervention study of cognitive function, aging, exercise, and health promotion. METHODS: Physical performance speed on gait and mobility tasks was measured via usual gait speed and the TUG (at fast pace). Executive function was measured with the TMT-B and Stroop-Interference measures. RESULTS: Applying multiple linear regression, usual gait speed was associated with executive function on both the TMT-B (ß=-0.215, P=.003) and Stroop-Interference (ß=-0.195, P=.01) measures, indicating that slower usual gait speed was associated with lower executive function performance. Timed "Up & Go" Test scores (in logarithmic transformation) also were associated with executive function on both the TMT-B (ß=0.256, P<.001) and Stroop-Interference (ß=0.228, P=.002) measures, indicating that a longer time on the TUG was associated with lower executive function performance. All associations remained statistically significant after adjusting for age, sex, depressive symptoms, medical comorbidity, and body mass index. LIMITATIONS: The cross-sectional nature of this study does not allow for inferences of causation. CONCLUSIONS: Physical performance speed was associated with executive function after adjusting for age, sex, and age-related factors in sedentary older adults with aMCI. Further research is needed to determine mechanisms and early intervention strategies to slow functional decline.