Perturbation-based balance training of older adults and effects on physiological, cognitive and sociopsychological factors: a secondary analysis from a randomised controlled trial with 12-month follow-up.

BACKGROUND: Perturbation-based balance training (PBT) has shown promising, although diverging, fall-preventive effects; however, the effects on important physical, cognitive and sociopsychological factors are currently unknown. The study aimed to evaluate these effects on PBT at three different time points (post-training, 6-months and 12-months) in community-dwelling older adults compared with regular treadmill walking. METHODS: This was a preplanned secondary analysis from a randomised, controlled trial performed in Aalborg, Denmark, between March 2021 and November 2022. Community-dwelling older adults aged ≥65 were randomly assigned to participate in four sessions (lasting 20 min each) of either PBT (intervention) or regular treadmill walking (control). All participants were assigned to four testing sessions: pretraining, post-training, 6-month follow-up and 12-month follow-up. At these sessions, physical, cognitive and sociopsychological measures were assessed. RESULTS: In total, 140 participants were randomly allocated to either the PBT or control group. Short-term (pretraining to post-training) between-group differences were seen for choice stepping reaction time (-49 ms, 95% CI -80 to -18), dual-task gait speed (0.05 m/s, 95% CI 0.01 to 0.09) favouring the PBT group. However, these improvements were not sustained at the 6-month and 12-month follow-up. No significant between-group differences were found in other physical, cognitive or sociopsychological factors. CONCLUSIONS: This study showed that PBT, in the short term, improved choice stepping reaction time and dual-task gait speed among community-dwelling older adults. Yet, these improvements were not retained for 6- or 12-months. The healthy state of the study's population may have imposed a ceiling effect limiting the ability to show any clinically relevant effects of PBT. TRIAL REGISTRATION NUMBER: NCT04733222.

International Consensus Recommendation Guidelines for Subcutaneous Infusions of Hydration and Medication in Adults: An e-Delphi Consensus Study.

Infusion of fluids and medications is traditionally performed intravenously. However, venous depletion in patients has led to the quest for vessel health preservation. A safe, effective, acceptable, and efficient alternative is the subcutaneous route. A lack of organizational policies may contribute to the slow uptake of this practice. This modified e-Delphi (electronic) study aimed to derive international consensus on practice recommendations for subcutaneous infusions of fluids and medications. A panel of 11 international clinicians, with expertise in subcutaneous infusion research and/or clinical practice, rated and edited subcutaneous infusion practice recommendations from evidence, clinical practice guidelines, and clinical expertise within an Assessment, Best Practice, and Competency (ABC) domain guideline model. The ABC Model for Subcutaneous Infusion Therapy provides a systematic guideline of 42 practice recommendations for the safe delivery of subcutaneous infusions of fluids and medications in the adult population in all care settings. These consensus recommendations provide a guideline for health care providers, organizations, and policy makers to optimize use of the subcutaneous access route.

Effect of Treadmill Perturbation-Based Balance Training on Fall Rates in Community-Dwelling Older Adults: A Randomized Clinical Trial.

Importance: Falls are common and the leading cause of injuries among older adults, but falls may be attenuated by the promising and time-efficient intervention called perturbation-based balance training (PBT). Objective: To evaluate the effects of a 4-session treadmill PBT intervention compared with regular treadmill walking on daily-life fall rates among community-dwelling older adults. Design, Setting, and Participants: This 12-month, assessor-blinded randomized clinical trial was conducted from March 2021 through December 2022 in Aalborg University in Denmark. Participants were community-dwelling adults 65 years or older and were able to walk without a walking aid. Participants were randomized to either PBT (intervention group) or treadmill walking (control group). Data analyses were based on the intention-to-treat principle. Interventions: Participants who were randomized to the intervention group underwent four 20-minute sessions of PBT, including 40 slip, trip, or mixed slip and trip perturbations. Participants who were randomized to the control group performed four 20-minute sessions of treadmill walking at their preferred speed. The 3 initial training sessions were completed within the first week, whereas the fourth session was performed after 6 months. Main Outcomes and Measures: Primary outcome was the daily-life fall rates that were collected from fall calendars for the 12 months after the third training session. Secondary outcomes were the proportion of participants with at least 1 fall and recurrent falls, time to first fall, fall-related fractures, fall-related injuries, fall-related health care contacts, and daily-life slip and trip falls. Results: A total of 140 highly functioning, community-dwelling older adults (mean [SD] age, 72 [5] years; 79 females [56%]), 57 (41%) of whom had a fall in the past 12 months, were included in this trial. Perturbation training had no significant effect on daily-life fall rate (incidence rate ratio [IRR]: 0.78; 95% CI, 0.48-1.27) or other fall-related metrics. However, there was a significant reduction in laboratory fall rates at the posttraining assessment (IRR, 0.20; 95% CI, 0.10-0.41), 6-month follow-up (IRR, 0.47; 95% CI, 0.26-0.86), and 12-month follow-up (IRR, 0.37; 95% CI, 0.19-0.72). Conclusions and Relevance: Results of this trial showed that participants who received an 80-minute PBT intervention experienced a statistically nonsignificant 22% reduction in daily-life fall rates. There was no significant effect on other daily-life fall-related metrics; however, a statistically significant decrease in falls was found in the laboratory setting. Trial Registration: ClinicalTrials.gov Identifier: NCT04733222.

Effect of a home-based isometric handgrip training programme on systolic blood pressure in adults: A randomised assessor-blinded trial.

OBJECTIVES: To evaluate the effects of 20 weeks of home-based isometric handgrip training (IHT) compared with usual care on systolic blood pressure (SBP) in adults. DESIGN AND PARTICIPANTS: This was a randomised, controlled, assessor-blinded trial. Participants were randomised to either IHT (intervention group) or usual care (control group). INTERVENTIONS: Participants randomised to the intervention group performed a session of 16 min of effective workout home-based IHT three times per week for 20 weeks. Participants randomised to the control group were asked to continue their daily activities as usual. OUTCOMES: The primary outcome was the difference in SBP between groups over 20 weeks. Secondary outcomes were diastolic blood pressure, heart rate, handgrip strength, and self-administered home blood pressure measures. RESULTS: Forty-eight adults (mean [SD] age, 64 [8] years) were included in this trial. The adjusted between-group mean difference in SBP was 8.12 mmHg (95% CI 0.24 to 16.01, p = 0.04) - favouring the usual care group. No differences between groups were found in any of the home blood pressure measurements. CONCLUSIONS: This trial showed that 20 weeks of home-based isometric handgrip training was not superior compared to the usual care in lowering SBP.

Absorption rate of subcutaneously infused fluid in ill multimorbid older patients.

BACKGROUND: Subcutaneous (SC) hydration is a valuable method for treating dehydration in the very old patients. Data are absent on the absorption rate, and the availability of SC infused fluid in the circulation in this group of patients where SC hydration is particularly relevant. METHODS: We performed an explorative study on ill very old (range 78-84 years old) geriatric patients with comorbidities who received an SC infusion of 235 ml isotonic saline containing a technetium-99m pertechnetate tracer. The activity over the infusion site was measured using a gamma detector to assess the absorption rate from the SC space. The activity was measured initially every 5 minutes, with intervals extended gradually to 15 minutes. Activity in blood samples and the thyroid gland was measured to determine the rate of availability in the circulation. RESULTS: Six patients were included. The mean age was 81 years (SD 2.1), the number of comorbidities was 4.6 (SD 1.3), and the Tilburg frailty indicator was 3.8 (SD 2.4). When the infusion was completed after 60 minutes, 53% (95% CI 50-56%) of the infused fluid was absorbed from the SC space, with 88% (95% CI 86-90%) absorbed one hour later. The absorption rate from the SC space right after the completion of the infusion was 127 ml/h (95% CI 90-164 ml/h). The appearance of the fluid into the blood and the thyroid gland verified the transfer from SC to circulation. CONCLUSION: This first explorative study of absorption of SC infused fluid in the very old found an acceptable amount of fluid absorbed from the SC space into the circulation one hour after infusion had ended. Results are uniform but should be interpreted cautiously due to the low sample size. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04536324.

Effects of treadmill slip and trip perturbation-based balance training on falls in community-dwelling older adults (STABILITY): study protocol for a randomised controlled trial.

INTRODUCTION: Falls among older adults are most frequently caused by slips and trips and can have devastating consequences. Perturbation-based balance training (PBT) have recently shown promising fall preventive effects after even small training dosages. However, the fall preventive effects of PBT delivered on a treadmill are still unknown. Therefore, this parallel-group randomised controlled trial aims to quantify the effects of a four-session treadmill-PBT training intervention on falls compared with treadmill walking among community-dwelling older adults aged 65 years or more. METHODS AND ANALYSIS: 140 community-dwelling older adults will be recruited and randomised into either the treadmill-PBT or the treadmill walking group. Each group will undergo three initial training sessions within a week and an additional 'booster' session after 26 weeks. Participants in the treadmill-PBT group will receive 40 slip and/or trip perturbations induced by accurately timed treadmill belt accelerations at each training session. The primary outcome of interest is daily life fall rates collected using fall calendars for a follow-up period of 52 weeks. Secondary outcomes include physical, cognitive and social-psychological fall-related risk factors and will be collected at the pre-training and post-training test and the 26-week and 52-week follow-up tests. All outcomes will be analysed using the intention-to-treat approach by an external statistician. A Poisson's regressions with bootstrapping, to account for overdispersion, will be used to compare group differences in fall rates. ETHICS AND DISSEMINATION: The study protocol has been approved by the North Denmark Region Committee on Health Research Ethics (N-20200089). The results will be disseminated in peer-reviewed journals and at international conferences. TRIAL REGISTRATION NUMBER: NCT04733222.

Adverse effects of subcutaneous vs intravenous hydration in older adults: An assessor-blinded randomised controlled trial (RCT).

BACKGROUND: Hydration therapy is essential in the care of the older patient. Subcutaneous (SC) hydration is a relevant method for parenteral hydration, but clinical trials on the subject have methodological shortcomings compared to updated standards. DESIGN: Assessor-blinded, non-inferiority RCT to explore if SC is a safe alternative to intravenous (IV) hydration. PARTICIPANTS: Eligible patients were: Admitted patients 65 years or older with a need for parenteral hydration. The targeted sample size was 67 patients in each group. INTERVENTION: Patients were randomised to parenteral hydration via an IV or SC catheter during a 24 hours observation period. The non-randomised catheter (inactive) was placed as a sham on the patient, thereby blinding the caregivers and outcome assessors. MEASUREMENT: Our primary outcome was the proportion of patients reporting at least one adverse effect with a non-inferiority calculation using a 20% margin. RESULTS: We included 51 patients, with 24 randomised to SC and 27 to IV. We were unable to reach our target sample size due to challenges in recruitment, time limitation, and COVID-19. For the outcome of adverse effects, SC was non-inferior to IV (p = 0.012). Time spent on inserting the catheters was shorter with SC (p = 0.001). The groups did not differ by pain of insertion, discomfort during infusion, or the risk of developing delirium. CONCLUSION: SC is a safe alternative to IV hydration, is faster to place and should be an available method for parenteral hydration wherever older adults are cared for. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03710408.

[Assessment of older patients upon admission at the emergency department].

Older patients admitted to the emergency departments represent a heterogeneous group, some are frail with reduced reserve capacity and without ability to compensate to acute illness. They often present with nonspecific complaints and atypical presentation and are at-risk of complications and adverse events. These patients need a fast comprehensive interdisciplinary and multicomponent assessment and intervention to reduce the risk of further functional decline and to optimize their overall health status, independency and quality of life. This is the purpose of acute geriatrics.

Effects of gait adaptability training on falls and fall-related fractures in older adults: a systematic review and meta-analysis.

OBJECTIVE: falls among older adults are common and can have devastating consequences. A novel task-specific exercise modality, gait adaptability training (GAT), has shown promising preventive effects. This systematic review and meta-analysis synthesise the evidence regarding GATs effect on falls and fall-related fractures in community-dwelling older adults. METHODS: electronic databases (PubMed, EMBASE, CINAHL, CENTRAL) were systematically searched from inception to 18 June 2020. Additional sources include searches of trial registrations, manual screening of reference lists and requests to experts. We included randomised controlled trials (RCTs) evaluating the effect of GAT on falls with at least 6-month follow-up among community-dwelling people aged 60+ years. Two reviewers independently screened studies against eligibility criteria, extracted relevant information and appraised studies for bias. Random-effects meta-analytic models were employed to pool effect estimates. RESULTS: eleven studies with 1,131 participants were included. A meta-analysis in which an outlier study was excluded showed that GAT reduces fall rates by 42% (incidence rate ratio 0.58, 95% confidence interval [CI] 0.39-0.81, I2 = 0.00%; moderate certainty; seven RCTs). Moreover, proportion with fall-related fractures and proportion of fallers was reduced by 81% (risk ratio [RR] 0.19, 95% CI 0.06-0.56, I2 = 0.00%; very low certainty; two RCTs) and 43% (RR 0.57, 95% CI 0.4-to 0.8, I2 = 47.08%; low certainty; 11 RCTs), respectively. CONCLUSIONS: our results show that GAT significantly reduces the number of falls and prevents fall-related fractures in older community dwellers. GAT is a promising and feasible exercise modality; however, studies of high quality should be conducted to support a robust conclusion. PROTOCOL REGISTRATION: PROSPERO; CRD42020191051.

Reliability and agreement of a novel portable laser height metre.

BACKGROUND: Human height is a simple measure with great applicability. Usually, stadiometers are used to measure height accurately. However, these may be impractical to transport and expensive. Therefore, we developed a portable and low-cost laser height metre (LHM). OBJECTIVE: We aimed to (1) determine intrarater and interrater reliability of our LHM and compare it to a wall-fixed stadiometer, (2) examine its agreement with the same stadiometer, and (3) determine the minimum number of recordings needed to obtain an accurate and reliable height measurement using the LHM. METHODS: We recruited 32 participants (18+ years)-both men and women. Two raters performed assessments on the same day blinded to each other and their reference standard measurements. We calculated intraclass correlation coefficient (ICC), coefficient of variation (CV), standard error of measurement (SEM), and Bland-Altman plots with limits of agreement (LOA). RESULTS: For both the LHM and stadiometer, we found ICC values of 0.99-1.00 (95% CI: 0.997-1.000) for both intrarater and interrater reliability. Regarding LHM intrarater reliability, SEM, CV, and LOA were 0.34 cm, 0.16%, and -1.07 to 0.73 cm, respectively. In terms of LHM interrater reliability, SEM, CV, and LOA were 0.27 cm, 0.12%, and -0.32 to 0.84 cm, respectively. As to agreement with stadiometers using one measurement, the mean difference was -0.14 cm and LOA ranged from -0.81 to 0.77 cm. CONCLUSION: A portable and low-cost LHM, for measuring body height once, showed an excellent reproducibility within and between raters along with an acceptable agreement with a stadiometer thereby representing a suitable alternative.

Harms and Benefits of Subcutaneous Hydration in Older Patients: Systematic Review and Meta-Analysis.

OBJECTIVE: To review all available original publications on the harms and benefits of subcutaneous (SC) hydration in older patients. DESIGN: Systematic review and meta-analysis. PARTICIPANTS: All studies on SC hydration in older patients without restrictions on design or language. MEASUREMENTS: The Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Web of Science databases and trial registries were searched from inception to November 5, 2019, and two reviewers independently extracted the data and assessed the risk of bias of individual outcomes. RESULTS: Thirty-one publications from 29 studies met the eligibility criteria. The data from six randomized controlled trials were used for the meta-analyses. The subgroup analysis including only the studies with the lowest risk of bias showed that SC hydration was associated with fewer adverse effects than intravenous (IV) hydration (risk ratio (RR) = 0.69; 95% confidence interval (CI) = 0.53-0.88; P = .003; n = 4; I2 = 0.0%; 545 infusions in each group). In absolute numbers, patients treated with SC hydration had an incidence rate of 90 adverse effects per 1,000 infusions versus 130 adverse effects per 1,000 infusions (95% CI = 102-169) with IV hydration. Secondary outcomes comparing IV with SC hydration showed that SC was 3.2 minutes faster to set up and markedly reduced the risk of agitation (RR = 0.42; 95% CI = 0.22-0.79; P = .007; I2 = 65%; n = 3); however, SC hydration delivered a lower volume of fluid and was less efficient at reducing serum osmolality (s-osmolality). CONCLUSIONS: SC hydration is safer than IV hydration and potentially reduces the risk of agitation, but it is less effective. SC hydration should be available as an alternative to IV hydration when treating older patients for mild-to-moderate dehydration. More high-quality studies are needed in the field to increase the confidence in the estimates.

Twenty weeks of isometric handgrip home training to lower blood pressure in hypertensive older adults: a study protocol for a randomized controlled trial.

BACKGROUND: Hypertension markedly increases the risk of cardiovascular diseases and overall mortality. Lifestyle modifications, such as increased levels of physical activity, are recommended as the first line of anti-hypertensive treatment. A recent systematic review showed that isometric handgrip (IHG) training was superior to traditional endurance and strength training in lowering resting systolic blood pressure (SBP). The average length of previous IHG training studies is approximately 7.5 weeks with the longest being 10 weeks. Therefore, presently it is unknown if it is possible to further lower blood pressure levels beyond the 10-week mark. Recently, we developed a novel method for monitoring handgrip intensity using a standard Nintendo Wii Board (Wii). The primary aim of this study is to explore the effects of a 20-week IHG home training facilitated by a Wii in hypertensive older adults (50 + years of age) on lowering SBP compared to usual care. Secondary aims are to explore if/when a leveling-off effect on SBP will occur during the 20-week intervention period in the training group and to explore adherence and potential harms related to the IHG home training. METHODS/DESIGN: Based on previous evidence, we calculated that 50 hypertensive (SBP between 140 and 179 mmHg), older adults (50 + years of age) are needed to achieve a power of 80% or more. Participants will be randomly assigned to either an intervention >group (IHG home training + hypertension guidelines on lifestyle changes) or to a control group (hypertension guidelines on lifestyle changes). Participants in the intervention group will perform IHG home training (30% of maximum grip strength for a total of 8 min per day per hand) three times a week for 20 weeks. Resting blood pressure and maximal handgrip strength will be obtained by a blinded outcome assessor in both groups at specific time points (baseline, follow-up at 5, 10, 15, and 20 weeks) throughout the study. DISCUSSION: This assessor-blinded, randomized controlled trial will explore the effect of a 20-week IHG home training intervention on resting blood pressure in hypertensive older adults. In addition, the trial will report adherence and potential harms related to the IHG home training. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03069443 . Registered on 3 March 2017.