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Background: Falls among older adults are a significant public health issue due to their high incidence, severe consequences, and substantial economic impact. Exercise programs incorporating balance and functional exercises have been shown to reduce fall rates, but adherence and scaling up the interventions remain challenges. Digital technology offers a promising avenue to deliver this type of exercise, potentially improving exercise adherence and enabling self-management of exercise in the aging population.

Objective: This study aims to assess the effectiveness of the Safe Step app, a self-managed, unsupervised, home-based digital exercise program, in reducing fall rates or fall risk in community-dwelling older adults. Additional aims were to describe fall-related injuries in both the exercise and control groups, study attrition, and adherence to the Safe Step exercise program.

Methods: Community-dwelling individuals, aged 70 years or older, who had experienced falls or a decline in balance in the past year were randomized to either an exercise group using the Safe Step app combined with educational videos, or a control group receiving educational videos alone. Both interventions lasted for 1 year. Information regarding fall events was self-reported monthly through questionnaires. Exercise adherence was monitored through questionnaires every third month. Negative binomial and logistic regression estimated the incidence rate ratio of fall rate and the risk ratio (RR) of experiencing falls, respectively. Fall-related injuries, study attrition, and exercise adherence were reported descriptively. Results: In total, 1628 people were enrolled in the study, 79% were women, and the mean age was 75.8 (SD 4.4) years (range 70-94 years). The intention-to-treat analysis showed no significant difference in fall rates between the exercise and control groups after 12 months (2.21 falls per person-year in the exercise group and 2.41 in the control group; incidence rate ratio 0.92, 95% CI 0.76-1.11; P=.37). The risk of experiencing at least 1 fall was significantly lower (11%) in the exercise group compared to the control group (53% vs 59.6%; RR 0.89, 95% CI 0.80-0.99; P=.03). No differences were observed regarding the risk of 2 or more falls (34.1% in the exercise group, 37.1% in the control group; RR 0.92, 95% CI 0.79-1.06; P=.23). Injurious fall rates were similar between the exercise and control group. During the trial, 161 (20%) participants from the exercise group and 63 (8%) from the control group formally withdrew. The proportion of exercise group participants meeting the 90-minute weekly exercise goal was 12.7%, 13.4%, 8.6%, and 9.1% at 3, 6, 9, and 12 months, respectively.

Conclusions: Access to a self-managed unsupervised digital exercise program can be an effective component of a primary fall prevention strategy for community-dwelling older adults. Further research is needed to explore the mediating factors that influence the outcomes and develop strategies that enhance adherence for optimal impact in this population.

Background: Accidental falls are one of the greatest threats to older adults’ health and well-being. The risk of falling can be significantly reduced with strength and balance interventions. However, there needs to be further knowledge into how older adults can be supported to achieve a maintained exercise behaviour. Therefore, the aim of this study was to explore factors that enabled older adults to maintain their exercise during a 1-year self-managed digital fall prevention exercise intervention.

Methods: This study used a grounded theory methodology. Semi-structured individual interviews were conducted by phone or conference call. Eighteen community-dwelling older adults aged 70 years or more participated. The participants had a self-reported exercise dose of 60 min or more per week during the last three months of participation in a 12-months intervention of self-managed digital fall prevention exercise, the Safe Step randomized controlled trial. Open, axial, and selective coding, along with constant comparative analysis, was used to analyze the data.

Results: The analysis resulted in a theoretical model. We found that the fall prevention exercise habits of adults were developed through three stages: Acting against threats to one’s own identity, Coordinating strategies to establish a routine, and Forming habits through cues and evaluation. The main category of Maintaining balance in life encases the participants transition through the three stages and reflects balance in both physical aspects and in between activities in daily life. The process of maintaining balance in life and desire to do so were mediated both by intrinsic person-dependent factors and the Safe Step application acting as an external mediator.

Conclusion: This study identified three stages of how older adults developed self-managed fall prevention exercise habits, supported by a digital application. The generated theoretical model can inform future interventions aiming to support long-term engagement in digitally supported and self-managed fall prevention interventions.

Background: Adults with dementia have a high risk of falls and fall-related injuries. A greater slowing of backward walking speed (BWS) relative to forward (FWS) has been indicated with older age, and slower BWS has been related to an increased risk of falls. Similarly, slow BWS relative to FWS has been observed in people with dementia.

Research question: Is slower BWS, and slower BWS relative to FWS associated with increased risk of prospective falls in older adults with dementia?

Methods: In total, 52 women and 12 men with dementia living in nursing homes, mean age 86 years, and mean Mini-Mental State Examination score of 14.2 points were included. BWS and FWS was measured over 2.4 m, and the directional difference (DD) calculated (100*((FWS-BWS)/FWS)). Falls were followed for 6 months by review of fall incident reports in electronic medical records at nursing homes and the regional healthcare provider.

Results: Altogether, 95 falls occurred with mean incidence rate 3.1 falls per person-years. Of included participants, 15 (23%) fell once, and 17 (27%) fell twice or more. In negative binomial regression analyses, greater DD was associated with lower prospective incidence fall rate ratio, IRR (IRR= 0.96, p < .001), while BWS was not (IRR= 0.04, p = .126).

Significance: In this study of adults with dementia, slower BWS was not associated with prospective falls. However, slower BWS relative to forward (greater DD) was associated with fewer falls, and possibly a protective response. This is novel research, yet results are promising and indicate that assessing walking speed in multiple directions may inform fall risk in adults with dementia.

BACKGROUND: Little is known about associations between performance-based measurements and self-reported scales, nor about ceiling effects or sensitivity to change to evaluate effects in the target population for self-managed exercise interventions. This study aimed to explore the feasibility of using performance-based outcomes for gait speed, functional leg strength and balance, and self-reported outcomes of falls-efficacy and functional ability in two self-managed falls prevention exercise interventions for community dwelling older adults.

METHODS: Independent living, community-dwelling older adults (n = 67) exercised with one of two self-managed falls prevention exercise programmes, a digital programme (DP) or a paper booklet (PB) in a 4-month participant preference trial. Pre- and post-assessments, by blinded assessors, included Short Physical Performance Battery (SPPB) and 30s Chair stand test (30s CST). Participants completed self-reported questionnaires: Activities-specific and Balance Confidence scale (ABC), Iconographical Falls Efficacy Scale (Icon-FES), Late-Life Function and Disability Instrument Function Component (LLFDI-FC). In addition, improvement in balance and leg strength was also self-rated at post-assessment. Participants' mean age was 76 ± 4 years and 72% were women.

RESULTS: Ceiling effects were evident for the balance sub-component of the SPPB, and also indicated for ABC and Icon-FES in this high functioning population. In SPPB, gait speed, 30s CST, and LLFDI-FC, 21-56% of participants did not change their scores beyond the Minimal Clinically Important Difference (MCID). At pre-assessment all performance-based tests correlated significantly with the self-reported scales, however, no such significant correlations were seen with change-scores. Improvement of performance-based functional leg strength with substantial effect sizes and significant correlations with self-reported exercise time was shown. There were no differences in outcomes between the exercise programmes except that DP users reported improved change of leg strength to a higher degree than PB users.

CONCLUSION: The LLFDI-FC and sit-to-stand tests were feasible and sensitive to change in this specific population. The balance sub-component of SPPB and self-reported measures ABC and Icon-FES indicated ceiling effects and might not be suitable as outcome measures for use in a high functioning older population. Development and evaluation of new outcome measures are needed for self-managed fall-preventive interventions with high functioning community-dwelling older adults.

Background: There is robust evidence that falls in old age can be prevented by exercise programs that include balance training, functional exercises, and strength training. For the interventions to have a population health impact, outreach to the population of focus with suitable interventions is needed. While digital interventions are promising there is limited knowledge on the characteristics of who is reached. The aim of this study was to describe the recruitment process, estimate reach rate at the population level and to describe participants characteristics and representativeness in a digital fall prevention intervention study.

Methods: In a municipality-based observational study, reach of a digital fall prevention intervention was evaluated. The intervention included a digital exercise programme (Safe Step) and optional supportive strategies, complemented with a range of recruitment strategies to optimize reach. Recruitment during a period of 6 months was open to people 70 years or older who had experienced a fall or a decline in balance the past year. Reach was based on data from the baseline questionnaire including health and demographic characteristics of participants. Representativeness was estimated by comparing participants to a sample of older people from the Swedish National Public Health Survey.

Results: The recruitment rate was 4.7% (n = 173) in relation to the estimated population of focus (n = 3,706). Most participants signed up within the first month of the intervention (n = 131). The intervention attracted primarily women, older people with high education, individuals who used the internet or digital applications almost every day and those perceiving their balance as fair or poor. Safe step participants lived more commonly alone and had higher education and better walking ability in comparison to the Swedish National Public Health Survey.

Conclusions: With a range of recruitment strategies most participants were recruited to a digital fall intervention during the first month. The intervention attracted primarily highly educated women who frequently used the internet or smart technologies. In addition to digital fall prevention interventions, a higher diversity of intervention types (digital and non-digital) is more likely to reach a larger group of older people with different needs.

Background: To have an impact on the population's health, preventive interventions have to reach a large proportion of the intended population. Digital solutions show potential for providing wider access to fall preventive exercise. However, there is a lack of knowledge about how to reach the target group. The aim of this study was to describe the recruitment process used in the Safe Step randomised controlled trial and the characteristics of the participants reached.

Methods: Several recruitment methods, both digital and non-digital, were adopted to reach the intended sample size. Sociodemographic parameters from the baseline questionnaire were used to describe participant characteristics. The characteristics were also compared to a representative sample of older adults in the Swedish population.

Results: In total, 1628 older adults were recruited. Social media proved to be the most successful recruitment strategy, through which 76% of the participants were recruited. The participants reached had a mean age of 75.9 years, lived in both urban and rural locations, were already frequent users of the Internet and applications (smartphone/tablet) (79.9%), had higher education (71.9%), and a large proportion were women (79.4%). In comparison with the general population participants in the Safe Step study were more highly educated (p < 0.001), women in the study more frequently lived alone (p < 0.001) and men more often reported poorer self-rated health (p = 0.04). Within the study, men reported a faster deteriorating balance (p = 0.003) and more prescribed medication (p < 0.001) than women.

Conclusion: Recruitment via social media is a useful strategy for reaching older adults, especially women and frequent users of the Internet, for a fully self-managed and digital fall prevention exercise intervention. This study underlines that a range of interventions must be available to attract and suit older adults with different functional statuses and digital skills.

Background: Multidirectional walking, including backward walking, is integral to daily activities, and seems particularly challenging in older age, and in people with pathology affecting postural control such as dementia.

Research Question: Does exercise influence backward walking speed in people with dementia, when tested using habitual walking aids and without, and do effects differ according to walking aid use?

Methods: This study included 141 women and 45 men (mean age 85 years) with dementia from the Umeå Dementia and Exercise (UMDEX), a cluster-randomized controlled trial study set in 16 nursing homes in Umeå, Sweden. Participants were randomized to a High-Intensity Functional Exercise (HIFE) program targeting lower limb strength-, balance and mobility exercise or to a seated attention control activity. Blinded assessors measured 2.4-meter usual backward walking speed, at baseline, 4 - (intervention completion) and 7-month follow-up; tested 1) with habitual walking aids allowed, and 2) without walking aids.

Results: Linear mixed models showed no between-group effect in either backward walking speed test at 4 or 7 months; test 1) 0.005 m/s, P = .788 and –0.006 m/s, P = .754 and test 2) 0.030 m/s, P = .231 and 0.015 m/s, P = .569, respectively. In interaction analyses, exercise effects differed significantly between participants who habitually walked unaided compared with those that used a walking aid at 7 months (0.094 m/s, P = .027).

Significance: In this study of older people with dementia living in nursing homes, the effects of exercise had no overall effects on backwards walking speed. Nevertheless, some benefit was indicated in participants who habitually walked unaided, which is promising and merits further investigation in future studies.

BACKGROUND: Gait and balance impairment are typical symptoms of idiopathic normal pressure hydrocephalus (INPH), implicating that falls may afflict these patients.

OBJECTIVE: To investigate falls, related injuries, and associated psychological features, before and after shunt surgery for INPH and compared to the general population.

METHODS: The study included 176 patients shunted for INPH and 368 age- and sex-matched controls. Falls, fear of falling (FOF), fall-related injuries (mild-severe), confidence in avoiding falls (Swedish Falls Efficacy Scale (FES(S)), quality of life (QoL; EuroQoL 5-dimension 5 level instrument), and symptoms of depression (Geriatric Depression Scale 15) were investigated. Pre- and postoperative observational times were 12 mo before surgery and 21 mo after (mean). Recurrent fallers fell ≥2 times.

RESULTS: More INPH patients than controls were recurrent fallers (67% vs 11%; P < .001). They feared falling more often (FOF, mean ± standard deviation: 3.3 ± 1.1 vs 1.6 ± 0.9; P < .001) and had lower confidence in avoiding falls (FES(S) 78 ± 40 vs 126 ± 14; P < .001). After surgery, INPH patients improved in all parameters but they did not reach the levels of the controls. Among fallers there was no difference between patients and controls in the severity of injuries suffered. Low QoL and symptoms of depression were more common among recurrent fallers than one-time or nonfallers in both shunted patients and controls (P ≤ .001).

CONCLUSION: Falls, FOF, and low confidence in avoiding falls are considerable problems in INPH that may be reduced by shunt surgery. We suggest that remaining risk of falling and preventative measures are routinely considered in postoperative follow-ups and rehabilitation planning.

Few studies have investigated the measurement error of the Mini-Mental State Examination (MMSE) in the same unit of measurement, also known as absolute reliability. This measurement can help determine whether an observed score change for an individual is likely to represent true change. The aim of this study was to investigate the absolute reliability of the MMSE among individuals with dementia that reside in nursing homes. Among 88 participants, 19 (21.6%) were men, 35 (39.8%) had Alzheimer's disease, 35 (39.8%) had vascular dementia, and the mean age was 84.0 years (range 65-98). The participants were tested and retested with the MMSE within 1-6 days. Both tests were administered by the same assessor at the same time of day. The mean MMSE score was 13.7 (range 0-28). The absolute difference between MMSE scores varied from 0 to 6 points, and the differences did not correlate with the corresponding score means (p = 0.874). The smallest detectable change (SDC) between two measurements was 4.00. The SDC was independent of depression, impaired vision and hearing, delirium within the last week, dementia type and age. However, the SDC was 5.56 among men and 3.50 among women (p = 0.003). In conclusion, for individuals with dementia that reside in nursing homes, it seems like their MMSE score needs to change by four or more points between two measurements in order for their score change to be reliably higher than the measurement error.

Background: Exercise is an effective intervention to prevent falls in older adults; however, long-term adherence is often poor. To increase adherence, additional support for behavior change has been advocated. However, consistency in the reporting of interventions using behavior change techniques is lacking. Recently, a classification system has been developed to increase consistency in studies using behavior change techniques within the self-determination theory.

Objective: This study aimed to explore expressions of self-determination among community-dwelling older adults using a self-managed digital fall prevention exercise program comprising behavior change support (the Safe Step program), which was developed in co-creation with intended users.

Methods: The qualitative study design was based on open-ended responses to questionnaires, and individual and focus group interviews. A deductive qualitative content analysis was applied using the classification system of motivation and behavior change techniques as an analytical matrix, followed by an inductive analysis. Twenty-five participants took part in a feasibility study and exercised in their homes with the Safe Step program for 4 months. The exercise program was available on computers, smartphones, and tablets, and was fully self-managed.

Results: In the deductive analysis, expressions of support were demonstrated for all three basic human psychological needs, namely, autonomy, competence, and relatedness. These expressions were related to 11 of the 21 motivation and behavior change techniques in the classification system. The inductive analysis indicated that autonomy (to be in control) was valued and enabled individual adaptations according to different rationales for realizing exercise goals. However, the experience of autonomy was also two-sided and depended on the participants’ competence in exercise and the use of technology. The clarity of the program and exercise videos was seen as key for support in performance and competent choices. Although augmented techniques for social support were requested, support through relatedness was found within the program.

Conclusions: In this study, the Safe Step program supported the establishment of new exercise routines, as well as the three basic human psychological needs, with autonomy and competence being expressed as central in this context. Based on the participants’ experiences, a proposed addition to the classification system used as an analytical matrix has been presented.