Background

Evidence-based interventions to improve mobility in older people include balance, strength and cognitive training. Digital technologies provide the opportunity to deliver tailored and progressive programs at home. However, it is unknown if they are effective in older people, especially in those with cognitive impairment.

Objective

The aim of this study was to examine the efficacy of a novel tablet-delivered cognitive-motor program on mobility in older people with cognitive impairment.

Methods

This was a 6-month single-blind randomised controlled trial of older people living in the community with subjective and/or objective cognitive impairment. Participants randomised to the intervention were asked to follow a 120 min per week balance, strength and cognitive training program delivered via an app on an iPad. Both the intervention and control group received monthly phone calls and health fact sheets. The primary outcome measure was gait speed. Secondary measures included dual-task gait speed, balance (step test, FISCIT-4), 5 sit to stand test, cognition (executive function, memory, attention), mood and balance confidence. Adherence, safety, usability and feedback were also measured.

Results

The planned sample size of 110 was not reached due to COVID-19 restrictions. A total of 93 (mean age 72.8 SD 7.0 years) participants were randomised to the two groups. Of these 77 participants returned to the follow-up clinic. In intention-to-treat analysis for gait speed, there was a non-significant improvement favouring the intervention group (β 0.04 m/s 95% CI -0.01, 0.08). There were no significant findings for secondary outcomes. Adherence was excellent (84.5%), usability of the app high (76.7% SD 15.3) and no serious adverse events were reported. Feedback on the app was positive and included suggestions for future updates.

Conclusion

Due to COVID-19 the trial was under powered to detect significant results. Despite this, there was a trend towards improvement in the primary outcome measure. The excellent adherence and positive feedback about the app suggest a fully powered trial is warranted.

Background and purpose: With an aging population, falls have become an increasing public health concern. While face-to-face exercise programs have demonstrated efficacy in reducing falls, their effectiveness is hampered by low participation and adherence. Digital technologies are a novel and potentially effective method for delivering tailored fall prevention exercise programs to older adults. In addition, they may increase the reach, uptake, and sustainability of fall prevention programs. Therefore, understanding older adults’ experiences of using technology-driven methods is essential. This study explored the user experience of StandingTall , a home-based fall prevention program delivered through a tablet computer.

Methods: Fifty participants were recruited using purposive sampling, from a larger randomized controlled trial. Participants were selected to ensure maximum variability with respect to age, gender, experience with technology, and adherence to the program. Participants undertook a one-on-one structured interview. We followed an iterative approach to develop themes.

Results and discussion: Eight themes were identified. These fall under 2 categories: user experience and program design. Participants found StandingTall enjoyable, and while its flexible delivery facilitated exercise, some participants found the technology challenging. Some participants expressed frustration with technological literacy, but most demonstrated an ability to overcome these challenges, and learn a new skill. Older adults who engaged in a technology-driven fall prevention program found it enjoyable, with the flexibility provided by the online delivery central to this experience. While the overall experience was positive, participants expressed mixed feelings about key design features. The embedded behavior change strategies were not considered motivating by most participants. Furthermore, some older adults associated the illustrated characters with gender-based stereotypes and negative views of aging, which can impact on motivation and preventive behavior.

Conclusion: This study found digital technologies are an effective and enjoyable method for delivering a fall prevention program. This study highlights that older adults are interested in learning how to engage successfully with novel technologies.

Objective

To assess the feasibility and safety of StandingTall—an individually tailored, progressive exercise program delivered through tablet computers—in community-dwelling older people with dementia.

Methods

Fifteen community-dwelling older people with dementia (mean age = 83 ± 8 years; Montreal Cognitive Assessment 16 ± 5) received StandingTall for 12 weeks with caregiver assistance. Feasibility and safety were assessed using the System Usability Scale (SUS; scores = 0-100; a priori target >65), Physical Activity Enjoyment Scale (PACES-8; scores = 8-56), adherence (exercise minutes) and adverse events.

Results

Mean SUS scores were 68 ± 21/69 ± 15 (participants/caregivers). The mean PACES-8 score was 44 ± 8. In week 2, week 7 and week 12, mean (bias-corrected and accelerated 95% CI) exercise minutes were 37 (25-51), 49 (30-69) and 65 (28-104), respectively. In week 12, five participants exercised >115 minutes. One participant fell while exercising, without sustained injury.

Conclusions

StandingTall had acceptable usability, scored well on enjoyment and was feasible for participants. These results provide support for further evaluation of StandingTall in a randomised controlled trial with falls as the primary outcome.

For older people, physical inactivity increases fall risk as well as other preventable health conditions. Despite the well-documented benefits of physical activity, uptake and adherence continue to challenge efforts aimed at increasing physical activity and reducing falls. Nested within a randomized controlled trial, this study reports on the factors influencing the physical activity behavior of people, aged between 70 and 90 years, engaged in StandingTall, a home-based balance exercise program proven to reduce falls in the community. The perception of aging, physical activity in older age, and the delivery of exercise were identified as major themes, with the perception of aging an overarching theme influencing both preferences for physical activity in older age and exercise delivery. Findings demonstrate the importance of considering the role of aging, the influence aging has on physical activity and exercise behavior, and how aging influences the delivery and design of exercise programs including falls prevention activities for older people.

Background

Physical activity and nutrition are modifiable risk factors associated with a range of mental health and psychosocial outcomes in older adults. This trial evaluated the efficacy of a multicomponent digital health promotion intervention in reducing levels of psychological distress among adults aged 60+ years.

Methods

The MovingTogether intervention is a Facebook- and eHealth-delivered intervention, facilitated by allied health professionals, and incorporates healthy lifestyle education, tailored exercise guidance (including balance training), and social support. Participants (n = 80) aged 60+ years were randomly assigned to the intervention (n = 39) or waitlist control (n = 41) in a 1:1 ratio, treating household couples as one unit. The primary outcome was psychological distress and secondary outcomes included physical activity levels, social capital, concern about falling, loneliness, physical functioning, quality of life and physical activity enjoyment. Outcomes were measured at baseline, postintervention (Week 11) and at follow-up (Week 16) via self-report, online questionnaires. Linear mixed models and an intention-to-treat approach were applied to determine between-group differences. Adherence, retention and adverse events were also tracked, and participant experience interviews were evaluated through a directed qualitative content analysis.

Results

The MovingTogether intervention significantly reduced psychological distress in the intervention group compared to the control postintervention, with a medium effect size [mean change between groups = 2.34, 95% confidence interval (CI) 0.25, 4.43, P = .03, Cohen’s d = 0.59]. Change was maintained at follow-up (mean change between groups = 2.02, 95% CI: 0.27, 3.77, P = 0.03, Cohen’s d = 0.31). No significant changes were found in secondary outcomes. Thirty-one (39%) participants dropped out of the study by the postprogramme point.

Conclusion

The results suggest multicomponent digital health promotion interventions, combining lifestyle education, physical activity and social support, can improve the mental health of older adults. More research is needed to understand how to best utilise digital engagement strategies and improve retention in physical activity programmes for older adults.

Objective: To test whether StandingTall, a home based, e-health balance exercise programme delivered through an app, could provide an effective, self-managed fall prevention programme for community dwelling older people.

Design: Assessor blinded, randomised controlled trial.

Setting: Older people living independently in the community in Sydney, Australia.

Participants: 503 people aged 70 years and older who were independent in activities of daily living, without cognitive impairment, progressive neurological disease, or any other unstable or acute medical condition precluding exercise.

Interventions: Participants were block randomised to an intervention group (two hours of StandingTall per week and health education; n=254) or a control group (health education; n=249) for two years.

Main outcome measures: The primary outcomes were the rate of falls (number of falls per person year) and the proportion of people who had a fall over 12 months. Secondary outcomes were the number of people who had a fall and the number of injurious falls (resulting in any injury or requiring medical care), adherence, mood, health related quality of life, and activity levels over 24 months; and balance and mobility outcomes over 12 months.

Results: The fall rates were not statistically different in the two groups after the first 12 months (0.60 falls per year (standard deviation 1.05) in the intervention group; 0.76 (1.25) in the control group; incidence rate ratio 0.82, 95% confidence interval 0.66 to 1.02, P=0.070). Additionally, the proportion of people who fell was not statistically different at 12 months (34.6% in intervention group, 40.2% in control group; relative risk 0.90, 95% confidence interval 0.72 to 1.12, P=0.348). However, the intervention group had a 16% lower rate of falls over 24 months (incidence rate ratio 0.84, 95% confidence interval 0.72 to 0.98, P=0.027) and a 20% lower rate of injurious falls over 24 months compared with the control group (incidence rate ratio 0.80, 95% confidence interval 0.66 to 0.98, P=0.031). Both groups had a similar proportion of people who fell over 24 months (relative risk 0.87, 95% confidence interval 0.74 to 1.02, P=0.077). In the intervention group, 68.1% and 52.0% of participants exercised for a median of 114.0 min/week (interquartile range 53.5) after 12 months and 120.4 min/week (38.6) after 24 months, respectively. Groups remained similar in mood and activity levels. The intervention group had a 0.03 (95% confidence interval 0.01 to 0.06) improvement on the EQ-5D-5L (EuroQol five dimension five level) utility score at six months, and an improvement in standing balance of 11 s (95% confidence interval 2 to 19 s) at six months and 10 s (1 to 19 s) at 12 months. No serious training related adverse events occurred.

Conclusions: The StandingTall balance exercise programme did not significantly affect the primary outcomes of this study. However, the programme significantly reduced the rate of falls and injurious falls over two years, with similar but not statistically significant effects at 12 months. E-health exercise programmes could provide promising scalable fall prevention strategies.

Falls among community-dwelling older adults represent a major public health challenge in Australia, and globally. Every day, about 400 older Australians are admitted to hospital due to falls. The consequences can be life-changing, with fall-related injuries often leading to long term disability, loss of independence, social isolation and premature entry into long term care. These impacts extend beyond the individual, placing significant strain on families, carers and the broader health care system. Falls cost more than $2.8 billion annually and reduce the availability of health care resources for people of all ages. Despite evidence from more than 600 trials — summarised across 12 Cochrane reviews — indicating that 20–30% of falls are preventable, fall prevention in Australia remains fragmented, underfunded and inconsistently implemented. This perspective article reviews the evidence on traditional and innovative approaches to fall prevention in community-dwelling older adults, highlighting hybrid models that combine in-person programs with digital solutions to improve accessibility and cost-effectiveness.

Key Points

• Editorial to accompany: Retrospective evaluation of the
  world falls guidelines-algorithm in older adults.
• Falls are a leading cause of injury in older adults, yet translating evidence into practice remains a global challenge.
• Intermediate risk represents a pivotal opportunity for
  timely, low-cost interventions that prevent progression
  to high risk.
• Combining subjective tools like 3KQs with mobility
  assessments improves precision in identifying intermediate risk.
• Better risk stratification enables efficient fall prevention,
  emphasising self-management for most older adults.
• Governments must prioritise fall prevention by ensuring accessible services, supported through funding and
  infrastructure.

Background

StandingTall uses eHealth to deliver evidence-based balance and functional strength exercises. Clinical trials have demonstrated improved balance, reduced falls and fall-related injuries and high adherence. This study aimed to evaluate the implementation of StandingTall into health services in Australia and the UK.

Methods

Two hundred and forty-six participants (Australia, n = 184; UK, n = 62) were recruited and encouraged to use StandingTall for 2 h/week for 6-months. A mixed-methods process evaluation assessed uptake and acceptability of StandingTall. Adherence, measured as % of prescribed dose completed, was the primary outcome.

Results

The study, conducted October 2019 to September 2021 in Australia and November 2020 to April 2022 in the UK, was affected by COVID-19. Participants’ mean age was 73 ± 7 years, and 196 (81%) were female. Of 129 implementation partners (e.g. private practice clinicians, community exercise providers, community service agencies) approached, 34% (n = 44) agreed to be implementation partners. Of 41 implementation partners who referred participants, 15 (37%) referred ≥5. Participant uptake was 42% (198/469) with mean adherence over 6 months being 41 ± 39% of the prescribed dose (i.e. 39 ± 41 min/week) of exercise. At 6 months, 120 (76%) participants indicated they liked using StandingTall, 89 (56%) reported their balance improved (moderately to a great deal better) and 125 (80%) rated StandingTall as good to excellent. For ongoing sustainability, health service managers highlighted the need for additional resources.

Conclusions

StandingTall faced challenges in uptake, adoption and sustainability due to COVID-19 and a lack of ongoing funding. Adherence levels were lower than the effectiveness trial, but were higher than other exercise studies. Acceptance was high, indicating promise for future implementation, provided sufficient resources and support are made available.