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Exploring the mechanism of change in exercise behavior during a theory-based exercise intervention among community-dwelling (pre)frail older adults: A stepped wedge cluster randomized trial
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Objectives: To systematically review the epidemiology of frailty in China, one of the world’s most populous countries, and to provide insightful guidance for countries to deal with fast population ageing.
Methods: Six electronic databases were searched until November 2022. Data from cross-sectional studies with a clear definition of frailty and a mean age ≥60 years were pooled using meta-analysis.
Results: 64 studies ( n = 106,826 participants) from 23 (67.6%) of China’s provinces were included. The overall prevalence of frailty and prefrailty among older community dwellers was 10.1% (95% CI: 8.5%–11.7%) and 43.9% (95% CI: 40.1%–47.8%), respectively. Adults over 70 years, women, unmarried, living alone, and those with less education had higher odds of being frail. Furthermore, regional disparities in frailty were observed; people in rural areas or areas with worse economic conditions had a higher prevalence of frailty.
Conclusion: A great variation in frailty prevalence was observed between subgroups of older adults stratified by common risk factors. The Chinese government should pay more attentions to seniors at high risk and regions with a high prevalence of frailty.
The world’s population is ageing, and most older adults experience a later life burdened with disease and disability. Frailty is a multi-dimensional and dynamic condition characterised by declines in reserve and function across multiple physiologic systems, such that the ability to cope with every day or acute stressors becomes compromised. It is projected to become one of the most serious public health challenges economically developed societies will face in the coming century. This review provides a comprehensive overview of frailty, exploring its pathophysiology, theoretical and operational definition(s), impact, prevalence, management, and prevention, within the context of its emergence as a major public health challenge, in an increasingly economically developed and ageing world. Further, this review discusses the major limitations, deficiencies, and knowledge gaps presently within the field, and future research directions pertinent to the advancement of frailty research and the promotion of healthy longevity among the increasing global population of older adults.
Aim
This study is aimed to evaluate the effectiveness of a theory‐driven exercise intervention for Chinese community‐dwelling (pre)frail older adults, and to clarify the underlying mechanisms of the exercise intervention in this population.
Design
A stepped‐wedge cluster‐randomized trial.
Methods
A stepped‐wedge cluster‐randomized trial will be conducted among (pre)frail older adults at six communities in a county of central China. A 12‐week multicomponent exercise intervention based on the integration of the Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB) will be implemented to all participants during the study period. The primary outcomes are frailty, muscle mass, muscle strength and physical performance. Secondary outcomes include beliefs in exercise, exercise behaviours and other physical, mental and social functioning. Assessments will be conducted at baseline and at week 12, 24 and 36. A multilevel regression model will be used to evaluate the effectiveness of exercise interventions. A multilevel mediation model will be used to clarify the underlying mechanisms of this exercise intervention.
Discussion
This study is expected to provide an effective and practical mode for exercise interventions among Chinese community‐dwelling (pre)frail older adults, and contribute to the existing evidence in this field.
Trial registration
Chinese Clinical Trial Registry ChiCTR2100041981.
A wearable activity tracker (WAT) incorporated with behavioral change techniques (BCTs) increases physical activity in younger adults; however, its effectiveness with frail older adults is unknown. The feasibility and preliminary effects of a WAT-based exercise intervention to increase physical activity levels in frail older adults was investigated in this pilot study involving 40 community-dwelling frail older adults. The experimental group received a 14-week WAT-based group exercise intervention and a 3-month follow-up, while the control group only received similar physical training and all BCTs. The recruitment rate was 93%, and the average attendance rate was 85.2% and 82.2% in the WAT and control groups, respectively, establishing feasibility. Adherence to wearing the WAT was 94.2% and 92% during the intervention and follow-up periods, respectively. A significant interaction effect between time and group was found in all physical assessments, possibly lasting for 3 months post-intervention. However, no significant difference between groups was observed in any daily activity level by the ActiGraph measurement. The majority of the WAT group’s ActiGraph measurements reverted to baseline levels at the 1-month follow-up. Thus, the WAT-based exercise program has potential for employment among community-dwelling frail older adults, but sustaining the effects after the intervention remains a major challenge.
Background and purpose:
Because of its high prevalence and association with negative health-related outcomes, frailty is considered one of the most important issues associated with human aging and its mitigation is among the essential public health goals for the 21st century. However, very few studies have focused on institutionalized older adults, despite the knowledge that frailty can be reversible when identified and treated from its earliest stages. Therefore, the objective of this study was to evaluate the effects of a supervised group-based multicomponent exercise program intervention with or without oral nutritional supplementation on functional performance in frail institutionalized older adults.
Methods:
This was a multicenter randomized controlled trial study with a 6-month intervention period. A total of 111 frail institutionalized older adults (75 years or older) who met at least 3 of the 5 Fried frailty criteria were randomly allocated to the control group (CG; n = 34, mean age = 87.3 ± 5.3 years), a supervised group-based multicomponent Otago Exercise Program group (OEP; n = 39, mean age = 86 ± 5.9 years), or a supervised group-based multicomponent exercise program intervention with oral nutritional supplementation (OEP+N; n = 38, mean age = 84.9 ± 6 years). Measurements included the Timed Up and Go test (TUG), Berg Balance Scale (BBS), Short Physical Performance Battery, repeated chair stand test (STS-5), handgrip strength (HGS), 10-m walking test, and 6-minute walking test, both at baseline and after the 6-month intervention period.
Results and discussion:
The between-group analysis by 2-way analysis of covariance showed significant improvement in the TUG [{OEP vs CG: -8.2 seconds, 95% CI [-13.3 to -2.9]; P < .001}; {OEP vs OEP+N: -7.3 seconds, 95% CI [-12.4 to -2.2]; P = .002}], BBS [{OEP vs CG; 8.2 points, 95% CI [5.2 to 11.2]; P < .001}; [{OEP+N vs CG: 4.6 points, 95% CI [1.6 to 7.6]; P < .001}; {OEP vs OEP+N: 3.5 points, 95% CI [0.6 to 6.5]; P = .011}], and HGS [{OEP vs CG: 3.4 kg, 95% CI [1.5 to 5.3]; P < .001}; {OEP+N vs CG: 3.6 kg, 95% CI [1.7 to 5.5]; P < .001}]. Additionally, the within-group analysis showed a significant improvement in the TUG (-6.9 seconds, 95% CI [-9.8 to -4.0]; P < .001) and BBS (4.3 points, 95% CI [2.6 to 5.9]; P < .001) in the OEP group. A significant decrease in the BBS and HGS was shown in the CG.
Conclusions:
A 6-month supervised group-based multicomponent exercise intervention improved the levels of mobility, functional balance, and HGS in frail institutionalized older adults. Further research will be required to evaluate the nutritional supplementation effects on functional performance to better determine its clinical applicability for tackling frailty.
Background:
Few studies examined interventions in frail elderly in China, while the awareness of applying interventions to prevent frailty in pre-frail elderly is still lacking. This study aimed to explore the effects of lower limb resistance exercise in pre-frail elderly in China.
Methods:
This was a randomized controlled trial of patients with pre-frailty. The control group received routine care, while the exercise group received a 12-week lower limb resistance exercise based on routine care. The muscle strength in the lower limbs, physical fitness, and energy metabolism of the patients was evaluated at admission and after 12 weeks of intervention.
Results:
A total of 60 pre-frail elderly were included in this study. The patients were divided into the exercise group (n = 30) and control group (n = 30) by random grouping. There were 17 men and 13 women aged 65.3 ± 13.4 in the exercise group, and 15 men and 15 women aged 67.6 ± 11.9 years in the control groups. The Barthel index was 80.3 ± 10.6 and 85.1 ± 11.6, respectively. The characteristics of the two groups were not significantly different before intervention (all p > 0.05). The results of repeated measurement ANOVA showed that there was statistically significant in crossover effect of group * time (all p < 0.05), that is, the differences of quadriceps femoris muscle strength, 6-min walking test, 30-s sit-to-stand test, 8-ft "up & go" test, daily activity energy expenditure and metabolic equivalent between the intervention group and the control group changed with time, and the variation ranges were different. The main effects of time were statistically significant (all p < 0.05), namely, femoris muscle strength, 6-min walking test, 30-s sit-to-stand test, 8-ft "up & go" test, daily activity energy expenditure and metabolic equivalent of the intervention group and the control group were significantly different before and after intervention. The main effects of groups were statistically significant (p < 0.05), namely, femoris muscle strength, 6-min walking test, 30-s sit-to-stand test, daily activity energy expenditure and metabolic equivalent before and after intervention were significantly different between the intervention group and the control group, while there was no significant differences in 8-ft "up & go" test between groups.
Conclusion:
Lower limb resistance exercise used for the frailty intervention could improve muscle strength, physical fitness, and metabolism in pre-frail elderly.
Trial registration:
ChiCTR, ChiCTR2000031099. Registered 22 March 2020, http://www.chictr.org.cn/edit.aspx?pid=51221&htm=4.
Background:
This study aimed to investigate the effects of supervised and home-based exercise programs on older people with frailty or pre-frailty.
Methods:
A total of 146 community-dwelling participants aged 65 and older who were prefrail or frail were randomly allocated into supervised exercise (N = 74) and home exercise (N = 72) groups. The 3-month supervised exercise training consisted of 3 exercise sessions per week, was performed at a hospital and supervised by a physical therapist. Home exercise participants took instructions on exercise and illustrated exercise handouts. The baseline and 3-month follow-up measurements included body composition, strength of selected upper and lower limb muscle groups, grip and leg press strengths, and five physical performance tests. Mixed-model repeated-measures analysis was applied to determine whether two groups differ in terms of changes before and after the intervention and to compare within-group improvements.
Results:
After 3 months of supervised or home-based exercise, the average number of frailty criteria met and fat percentage decreased significantly. Strength of knee extensors, knee flexors and leg press improved significantly in supervised exercise group. In home-based exercise group, the strength of all muscle groups tested improved significantly, except for leg press strength. Walking speed improved in both groups, and timed-up-and-go and timed chair rise tests improved significantly only in supervised exercise group.
Conclusions:
Three-month supervised or home-based exercise improved walking speed and strength of the limb muscles. Supervised group showed more improvements in the physical performance tests compared with home-based exercise group.
Background:
Knee osteoarthritis (KOA) is a common joint disease in people over 60 years old. Exercise therapy is one of the most effective non-pharmacological treatments for KOA, but low exercise adherence needs to be improved. The present study aimed to evaluate the effect of the transtheoretical model-lead home exercise intervention (TTM-HEI) program on exercise adherence, KOA symptoms, and knee function in older adults with KOA.
Methods:
A two-arm, superiority, assessor-blinded, cluster randomized trial was conducted. Community-dwelling older adults with KOA were recruited from 14 community centers in Beijing, China, via print and social media advertisements from April to October 2018. The present study lasted 48 weeks, with an intervention duration of 0-24 weeks and follow-up time of 24-48 weeks. The intervention was a two-stage and 24-week TTM-based exercise program, and the control group underwent a same-length exercise program guidance without any exercise adherence interventions. The primary outcome was exercise adherence to the prescribed home exercise program and was measured using an 11-point numerical (0 = not at all through and 10 = completely as instructed) self-rating scale at weeks 4, 12, 24, 36, and 48 after the program started. KOA symptoms (pain intensity and joint stiffness) were measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and knee function (lower limb muscle strength and balance) was measured using the Five-Times-Sit-to-Stand Test (FTSST) and the Timed Up and Go Test (TUG) at baseline, week 24, and week 48. Latent growth model (GLM), repeated measures ANOVA, and independent t test were the main statistical tests used.
Results:
A total of 189 older adults (intervention group: n = 103, control group: n = 86) were enrolled. Differences of any outcome measures at baseline were not significant between groups. The growth rate of exercise adherence in the intervention group increased 2.175 units compared with that in the control group (unstandardized coefficient of slope on group B2 = 2.175, p < 0.001), and the intervention program maintained participants' exercise adherence with 5.56 (SD = 1.00) compared with 3.16 (SD = 1.31) in the control group at week 48. In addition, the TTM-HEI program showed significant effects on relieving KOA symptoms and improving knee function.
Conclusion:
Over time, TTM-HEI could improve participants' exercise adherence, KOA symptoms, and knee function.
Trial registration:
This study was approved by the ethics committee (IRB00001052-17066) in July 2017 and was registered at the Chinese Clinical Trial Registry (website: www.chictr.org.cn, registry number: ChiCTR1800015458).
The efficacy of exercise to reverse frailty in the aging population has not been extensively investigated. This study aimed to investigate the effectiveness of a multicomponent exercise program (MCEP) on frailty, physical performance (handgrip strength, Berg Balance Scale (BBS), Timed Up and Go test (TUG), and VO2Max), blood biomarkers (Interleukin-6 (IL-6) and C-reactive protein (CRP)) in frail older adults. A randomized controlled trial using an allocation concealment method, included 64 older adults (77.78 ± 7.24 years), were divided into two parallel groups using block randomization: an MCEP group (n = 32) and a control group (n = 32). The combined center- and home-based MCEP training consisted of chair aerobic, resistance, and balance, which was carried out 3 days per week for 24 weeks. A mixed model repeated measure ANOVA demonstrated significant interaction effects of group x time for BBS, TUG and frailty scores (p < 0.001). Additionally, the post-hoc analysis revealed that the MCEP group showed significantly improved BBS, TUG, and frailty scores (p < 0.01), at both 12- and 24-weeks. When compared with controls at 12-weeks, the MCEP group decreased IL-6 and CRP levels (p < 0.05). The combined center- and home-based MCEP were effective in reversing frailty to pre-frailty and improving physical performance especially balance in the older population.
The stepped-wedge cluster randomized trial (SW-CRT) involves the sequential transition of clusters (such as hospitals, public health units or communities) from control to intervention conditions in a randomized order. The use of the SW-CRT is growing rapidly. Yet the SW-CRT is at greater risks of bias compared with the conventional parallel cluster randomized trial (parallel-CRT). For this reason, the CONSORT extension for SW-CRTs requires that investigators provide a clear justification for the choice of study design. In this paper, we argue that all other things being equal, the SW-CRT is at greater risk of bias due to misspecification of the secular trends at the analysis stage. This is particularly problematic for studies randomizing a small number of heterogeneous clusters. We outline the potential conditions under which an SW-CRT might be an appropriate choice. Potentially appropriate and often overlapping justifications for conducting an SW-CRT include: (i) the SW-CRT provides a means to conduct a randomized evaluation which otherwise would not be possible; (ii) the SW-CRT facilitates cluster recruitment as it enhances the acceptability of a randomized evaluation either to cluster gatekeepers or other stakeholders; (iii) the SW-CRT is the only feasible design due to pragmatic and logistical constraints (for example the roll-out of a scare resource); and (iv) the SW-CRT has increased statistical power over other study designs (which will include situations with a limited number of clusters). As the number of arguments in favour of an SW-CRT increases, the likelihood that the benefits of using the SW-CRT, as opposed to a parallel-CRT, outweigh its risks also increases. We argue that the mere popularity and novelty of the SW-CRT should not be a factor in its adoption. In situations when a conventional parallel-CRT is feasible, it is likely to be the preferred design.
Background:
Frail older adults are predisposed to multiple comorbidities and adverse events. Recent interventional studies have shown that frailty can be improved and managed. In this study, effective individualized home-based exercise and nutrition interventions were developed for reducing frailty in older adults.
Methods:
This study was a four-arm, single-blind, randomized controlled trial conducted between October 2015 and June 2017 at Miaoli General Hospital in Taiwan. Overall, 319 pre-frail or frail older adults were randomly assigned into one of the four study groups (control, exercise, nutrition, and exercise plus nutrition [combination]) and followed up during a 3-month intervention period and 3-month self-maintenance period. Improvement in frailty scores was the primary outcome. Secondary outcomes included improvements in physical performance and mental health. The measurements were performed at baseline, 1 month, 3 months, and 6 months.
Results:
At the 6-month measurement, the exercise (difference in frailty score change from baseline: - 0.23; 95% confidence interval [CI]: - 0.41, - 0.05; p = 0.012), nutrition (- 0.28; 95% CI: - 0.46, - 0.11; p = 0.002), and combination (- 0.34; 95% CI: - 0.52, - 0.16; p < 0.001) groups exhibited significantly greater improvements in the frailty scores than the control group. Significant improvements were also observed in several physical performance parameters in the exercise, nutrition, and combination groups, as well as in the 12-Item Short Form Health Survey mental component summary score for the nutrition group.
Conclusions:
The designated home-based exercise and nutrition interventions can help pre-frail or frail older adults to improve their frailty score and physical performance.
Trial registration:
Retrospectively registered at ClinicalTrials.gov (identifier: NCT03477097); registration date: March 26, 2018.
Objective: To discuss the effects of elastic band exercise on the frailty states in pre-frail elderly people.
Methods: This study was a randomized controlled trial. Trial registration number is ChiCTR-IOC-17012579. Seventy pre-frail elderly people were randomly divided into elastic band group (n = 35) and control group (n = 35). Elastic band exercise was applied to elastic band group, 45–60 min per time for 8 weeks by 3 days a week; no exercise was applied to the control group. The frailty states, grip strength (female/male), walking speed, and physical activity were measured by the Fried frailty phenotype at pre-intervention, 4, and 8 weeks after intervention to assess the effects of exercise.
Results: The elastic band group showed significant improvements in the frailty states, grip strength (female) and walking speed both after 4-week and 8-week intervention (P< 0.001), and significant improvements in grip strength (male) and physical activity after 8-week intervention (P< 0.05). Within-group analysis (pre-intervention vs. after 4-week, after 4-week vs after 8-week, pre-intervention vs after 8-week) showed significant improvements (P< 0.001) in grip strength (female/male) and walking speed in the elastic band group over time, while no significant differences in the control group (P > 0.05).
Conclusion: Elastic band exercise can improve frailty states in pre-frail elderly people, make them broke away from pre-frailty and restore them to non-frailty through improving the grip strength, walking speed and physical activity, and the effects after 8 weeks are better than those after 4 weeks.
Interventions to minimise, reverse or prevent the progression of frailty in older adults represent a potentially viable route to improving quality of life and care needs in older adults. Intervention methods used across European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) collaborators were analysed, along with findings from literature reviews to determine “what works for whom in what circumstances”.
A realist review of FOCUS study literature reviews, ‘real world’ studies and grey literature was conducted according to RAMESES standards, and used to populate a framework analysis of theories of why frailty interventions worked, and theories of why frailty interventions did not work. Factors were distilled into mechanisms deriving from theories of causes of frailty, management of frailty and those based on intervention process.
We found that studies based on resolution of a deficiency in an older adult, were only successful when there was indeed a deficiency. Client centred interventions worked well when they had a theoretical grounding in health psychology and offered choice over intervention elements. Healthcare organisational interventions were found to have an impact on success when they were sufficiently different from usual care. Compelling evidence for the reduction of frailty came from physical exercise, or multicomponent (exercise, cognitive, nutrition, social) interventions in group settings. The group context appears to improve participants’ commitment and adherence to the programme. Suggested mechanisms included commitment to co-participants, enjoyment and social interaction. In conclusion, initial frailty levels, presence or absence of specific deficits, and full person and organisational contexts should be included as components of intervention design. Strategies to enhance social and psychological aspects should be included even in physically focused interventions.
Background:
Frailty can be an important clinical target to reduce rates of disability.
Objective:
To ascertain if a supervised-facility multicomponent exercise program (MEP) when performed by frail older persons can reverse frailty and improve functionality; cognitive, emotional, and social networking; as well as biological biomarkers of frailty, when compared with a controlled population that received no training.
Design:
This is an interventional, controlled, simple randomized study. Researchers responsible for data gathering were blinded for this study.
Setting:
Participants from 2 primary rural care centers (Sollana and Carcaixent) of the same health department in Spain were enrolled in the study between December 2013 and September 2014.
Patients:
We randomized a volunteer sample of 100 men and women who were sedentary, with a gait speed lower than 0.8 meters per second and frail (met at least 3 of the frailty phenotype criteria).
Interventions:
Participants were randomized to a supervised-facility MEP (n = 51, age = 79.5, SD 3.9) that included proprioception, aerobic, strength, and stretching exercises for 65 minutes, 5 days per week, 24 weeks, or to a control group (n = 49, age = 80.3, SD 3.7). The intervention was performed by 8 experienced physiotherapists or nurses. Protein-calorie and vitamin D supplementation were controlled in both groups.
Results:
Our MEP reverses frailty (number needed to treat to recover robustness in subjects with attendance to ≥50% of the training sessions was 3.2) and improves functional measurements: Barthel (trained group 91.6 SD 8.0 vs 82.0 SD 11.0 control group), Lawton and Brody (trained group 6.9 SD 0.9 vs 5.7 SD 2.0 control group), Tinetti (trained group 24.5 SD 4.4 vs 21.7 SD 4.5 control group), Short Physical Performance Battery (trained group 9.5 SD 1.8 vs 7.1 SD 2.8 control group), and physical performance test (trained group 23.5 SD 5.9 vs 16.5 SD 5.1 control group) as well as cognitive, emotional, and social networking determinations: Mini-Mental State Examination (trained group 28.9 SD 3.9 vs 25.9 SD 7.3 control group), geriatric depression scale from Yesavage (trained group 2.3 SD 2.2 vs 3.2 SD 2.0 control group), EuroQol quality-of-life scale (trained group 8.2 SD 1.6 vs 7.6 SD 1.3 control group), and Duke social support (trained group 48.5 SD 9.3 vs 41.2 SD 8.5 control group). This program is unique in that it leads to a decrease in the number of visits to primary care physician (trained group 1.3 SD 1.4 vs 2.4 SD 2.9 control group) and to a significant improvement in frailty biomarkers.
Conclusions:
We have designed a multicomponent exercise intervention that reverses frailty and improves cognition, emotional, and social networking in a controlled population of community-dwelling frail older adults.
Trial registration:
ClinicalTrials.gov. Identifier: NCT02331459.
It is important to establish whether frailty among older individuals is reversible with nutritional, physical or cognitive interventions, singly or in combination. We compared the effects of 6-month duration interventions with nutritional supplementation, physical training, cognitive training, and combination treatment versus control in reducing frailty among community-dwelling pre-frail and frail older persons.
We conducted a parallel group, randomized controlled trial in community-living pre-frail and frail old adults in Singapore. The participants' mean age was 70.0 years, and 61.4% (n=151) were female. Five different 6-month interventions included nutritional supplementation (N=49), cognitive training (N=50), physical training (N=48), combination treatment (N=49) and usual care control (N=50). Frailty score, body mass index, knee extension strength, gait speed, energy/vitality, and physical activity levels and secondary outcomes (activities of daily living dependency, hospitalization and falls) were assessed at 0 month, 3 month, 6 month and 12 month.
Frailty score and status over 12 months were reduced in all groups, including control (15%), but were significantly higher (35.6% to 47.8%) in the nutritional (OR=2.98), cognition (OR=2.89) and physical (OR=4.05) and combination (OR=5.00) intervention groups. Beneficial effects were observed at 3 month and 6 month, and persisted at 12 month. Improvements in physical frailty domains (associated with interventions) were most evident for knee strength (physical, cognitive and combination treatment), physical activity (nutritional intervention), gait speed (physical intervention), and energy (combination intervention). There were no major differences with respect to the small numbers of secondary outcomes.
Physical, nutritional and cognitive interventional approaches were effective in reversing frailty among community-living older persons.
Copyright © 2015 Elsevier Inc. All rights reserved.
To examine the test-retest reliabilities and relative validities of the Chinese version of short International Physical Activity Questionnaire (IPAQ-S-C), the Global Physical Activity Questionnaire (GPAQ-C), and the Total Energy Expenditure Questionnaire (TEEQ-C) in a population-based prospective study, the Taizhou Longitudinal Study (TZLS).
A longitudinal comparative study.
A total of 205 participants (male: 38.54%) aged 30-70 years completed three questionnaires twice (day one and day nine) and physical activity log (PA-log) over seven consecutive days. The test-retest reliabilities were evaluated using intra-class correlation coefficients (ICCs) and the relative validities were estimated by comparing the data from physical activity questionnaires (PAQs) and PA-log.
Good reliabilities were observed between the repeated PAQs. The ICCs ranged from 0.51 to 0.80 for IPAQ-C, 0.67 to 0.85 for GPAQ-C, and 0.74 to 0.94 for TEEQ-C, respectively. Energy expenditure of most PA domains estimated by the three PAQs correlated moderately with the results recorded by PA-log except the walking domain of IPAQ-S-C. The partial correlation coefficients between the PAQs and PA-log ranged from 0.44 to 0.58 for IPAQ-S-C, 0.26 to 0.52 for GPAQ-C, and 0.41 to 0.72 for TEEQ-C, respectively. Bland-Altman plots showed acceptable agreement between the three PAQs and PA-log.
The three PAQs, especially TEEQ-C, were relatively reliable and valid for assessment of physical activity and could be used in TZLS.
Copyright © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
The International Physical Activity Questionnaire-Short Form (IPAQ-SF) has been recommended as a cost-effective method to assess physical activity. Several studies validating the IPAQ-SF have been conducted with differing results, but no systematic review of these studies has been reported.
The keywords "IPAQ", "validation", and "validity" were searched in PubMed and Scopus. Studies published in English that validated the IPAQ-SF against an objective physical activity measuring device, doubly labeled water, or an objective fitness measure were included.
Twenty-three validation studies were included in this review. There was a great deal of variability in the methods used across studies, but the results were largely similar. Correlations between the total physical activity level measured by the IPAQ-SF and objective standards ranged from 0.09 to 0.39; none reached the minimal acceptable standard in the literature (0.50 for objective activity measuring devices, 0.40 for fitness measures). Correlations between sections of the IPAQ-SF for vigorous activity or moderate activity level/walking and an objective standard showed even greater variability (-0.18 to 0.76), yet several reached the minimal acceptable standard. Only six studies provided comparisons between physical activity levels derived from the IPAQ-SF and those obtained from objective criterion. In most studies the IPAQ-SF overestimated physical activity level by 36 to 173 percent; one study underestimated by 28 percent.
The correlation between the IPAQ-SF and objective measures of activity or fitness in the large majority of studies was lower than the acceptable standard. Furthermore, the IPAQ-SF typically overestimated physical activity as measured by objective criterion by an average of 84 percent. Hence, the evidence to support the use of the IPAQ-SF as an indicator of relative or absolute physical activity is weak.
The seven articles in this issue, and the accompanying meta-analysis in Health Psychology Review [McEachan, R.R.C., Conner, M., Taylor, N., & Lawton, R.J. (2011). Prospective prediction of health-related behaviors with the theory of planned behavior: A meta-analysis. Health Psychology Review, 5, 97-144], illustrate the wide application of the theory of planned behaviour [Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211] in the health domain. In this editorial, Ajzen reflects on some of the issues raised by the different authors. Among the topics addressed are the nature of intentions and the limits of predictive validity; rationality, affect and emotions; past behaviour and habit; the prototype/willingness model; and the role of such background factors as the big five personality traits and social comparison tendency.
To evaluate the Health Action Process Approach (HAPA) as a motivational model for physical activity self-management for people with multiple sclerosis (MS).
Quantitative descriptive research design using path analysis.
One hundred ninety-five individuals with MS were recruited from the National Multiple Sclerosis Society and a neurology clinic at a university teaching hospital in the Midwest.
Outcome was measured by the Physical Activity Stages of Change Instrument, along with measures for nine predictors (severity, action self-efficacy, outcome expectancy, risk perception, perceived barriers, intention, maintenance self-efficacy, action and coping planning, and recovery self-efficacy).
The respecified HAPA physical activity model fit the data relatively well (goodness-of-fit index = .92, normed fit index = .91, and comparative fit index = .93) explaining 38% of the variance in physical activity. Recovery self-efficacy, action and coping planning, and perceived barriers directly contributed to the prediction of physical activity. Outcome expectancy significantly influenced intention and the relationship between intention and physical activity is mediated by action and coping planning. Action self-efficacy, maintenance self-efficacy, and recovery self-efficacy directly or indirectly affected physical activity. Severity of MS and action self-efficacy had an inverse relationship with perceived barriers and perceived barriers influenced physical activity.
Empirical support was found for the proposed HAPA model of physical activity for people with MS. The HAPA model appears to provide useful information for clinical rehabilitation and health promotion interventions.
Objectives:
This study aims to evaluate the effects of multicomponent exercise on the muscle strength, muscle endurance and balance of frail older adults living in the community and provide the latest evidence from published randomised controlled trials (RCTs).
Background:
The number of frail older adults is rapidly increasing. Previous studies have reported that multicomponent exercise is one of the best types of intervention for increasing muscle strength, muscle endurance and balance for frail older adults. However, due to the small sample size and lack of evidential support, a meta-analysis of RCTs remains necessary.
Methods:
RCTs reporting the effects of multicomponent exercise on the muscle strength, muscle endurance and balance of frail older adults, published in English, were retrieved from five electronic databases: PubMed, CINAHL, Web of Science, Embase and Cochrane Library available from their inception up to January 2021. RevMan5.3 software was adopted for statistical analysis. This study followed the PRSIMA checklist.
Results:
A total of 10 articles and 667 patients were included in this study. Meta-analysis showed that multicomponent exercise could improve the muscle strength [MD = 2.46, p = .007], muscle endurance [MD = 2.16, p = .03] and balance [MD = .39, p = .03] of frail older adults, and subgroup analysis showed the muscle endurance of frail older adults was significantly improved as the intervention lasted for >12 weeks.
Conclusions:
RCTs provided in this study show the latest evidence that multicomponent exercise can improve the muscle strength, endurance and balance of frail older adults and that long-duration (>12weeks) multicomponent exercise is more effective for improving muscle endurance.
Relevance to clinical practice:
Multicomponent exercise contributes to improving the muscle strength, muscle endurance and balance of frail older adults, so it can be considered as a complement to the physical function management programme for frail older adults.
Objectives
To investigate the effects of a 12-month home-based exercise program on functioning and falls among persons with signs of frailty.
Design
A randomized controlled trial with a 1:1 allocation
Setting
Home-based
Participants
Home-dwelling persons aged ≥65 years meeting at least one frailty phenotype criteria (n=300).
Intervention
12-month, individually tailored, progressive and physiotherapist-supervised, physical exercise twice a week (n=150) vs. usual care (n=149).
Main outcome Measures
Functional Independence Measure (FIM), Short Physical Performance Battery (SPPB), handgrip strength, instrumental activities of daily living (IADL), and self-reported falls and physical activity (other than intervention). Assessed four times at home over 12 months.
Results
The mean age of the participants was 82.2 (SD 6.3), 75% were women, 61% met 1–2 frailty criteria and 39% ≥3 criteria. FIM deteriorated in both groups over 12 months, -4.1 points (95% CI: -5.6 to -2.5) in the exercise group and -6.9 (-8.4 to -2.3) in the usual care group (group p=0.014, time p<0.001, interaction p=0.56). The mean improvement in SPPB was significantly greater in the exercise group [1.6 (1.3 to 2.0)] than in the usual care group [0.01 (-0.3 to 0.3)] (group p<0.001, time p=0.11, interaction p=0.027). The exercise group reported significantly fewer falls per person-year compared to the usual care group (incidence rate ratio, IRR 0.47 [95% CI 0.40 to 0.55]; p<0.001). There was no significant difference between the groups over 12 months in terms of handgrip strength, IADL function or self-reported physical activity.
Conclusions
One year of physical exercise improved physical performance and decreased the number of falls among people with signs of frailty. FIM differed between the groups at 12 months, but exercise did not prevent deterioration of FIM, IADL or handgrip strength.
This pilot study aimed to examine the feasibility and effectiveness of a 6-months multi-component exercise program combined with twice daily consumption of either rice (RicePro) or whey-based (WheyPro) protein supplements (2 × 20 g of protein) on gait speed, grip strength and physical performance in community-dwelling pre-frail and frail older adults. Secondary outcomes included: frailty score, muscle mass, quality of life, nutritional intake, cognitive performance, depression and physical activity levels. A total of 70 participants (mean age 73.34 ± 6.85 years) were randomly allocated to either RicePro (n = 36) or WheyPro (n = 34). No adverse events were reported in regards to the exercise, however, several gastrointestinal symptoms were noted with the whey protein causing two-fold more symptoms compared to the rice protein. No differences were found between the groups (p > 0.05), except the total consumed energy (kJ) (p = 0.014) and fat (g) (p = 0.012) which was significantly lower in WheyPro. The results indicate that the quality of protein may not be as important as long as a sufficient amount is consumed.
Objective
To develop and evaluate the psychometric properties of an instrument assessing beliefs in physical activity based on the integration of the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB) among (pre)frail older adults.
Methods
A literature review and semi-structured interviews were conducted to generate the initial item pool of the instrument. A rural sample of 611 (pre)frail older adults was enrolled to examine the validity and reliability of the instrument.
Results
The exploratory factor analysis extracted eight factors for this instrument, explaining 71.3% of the variance in beliefs in physical activity. The confirmatory factor analysis confirmed the eight-factor structure. Linear regression models found that the integrated HBM-TPB constructs explained 65.9% of the variance in physical activity intention and 13.6% in physical activity. The Cronbach’s alpha coefficients for the factors ranged from 0.80 to 0.98, and ICCs ranged from 0.71 to 0.85.
Conclusion
This instrument has satisfactory construct validity, predictive validity, internal consistency reliability and test-retest reliability, and it can be used in (pre)frail older adults to measure beliefs in physical activity.
Practice implications
This instrument may help health care providers understand beliefs in physical activity and facilitate targeted interventions among (pre)frail older adults.
Background
Frailty becomes a great challenge with population aging. The proactive identification of frailty is considered as a rational solution in the community. Previous studies found that frailty instruments had insufficient predictive accuracy for adverse outcomes, but they mainly focused on long-term outcomes and constructed frailty instruments based on available data not original forms. The predictive performance of original frailty instruments for short-term outcomes in community-dwelling older adults remains unknown.
Objective
To examine the predictive performance of seven frailty instruments in their original forms for 1-year incident outcomes among community-dwelling older adults.
Design
A prospective cohort study.
Settings
A total of 22 communities were selected by a stratified sampling method from one Chinese city.
Participants
A total of 749 older adults aged ≥ 60 years (mean age of 69.2 years, 69.8% female) were followed up after 1 year.
Methods
Baseline frailty was assessed by three purely physical dimensional instruments (i.e. Frailty Phenotype, the Study of Osteoporotic Fracture and FRAIL Scale) and four multidimensional instruments (i.e. Frailty Index, Groningen Frailty Indicator, Tilburg Frailty Indicator and Comprehensive Frailty Assessment Instrument), respectively. Outcomes included incident disability, falls, hospitalization and the combined outcome at 1-year follow-up. The receiver operating characteristic curves were plotted to assess the predictive performance of frailty instruments.
Results
The areas under the curves of seven frailty instruments in predicting incident outcomes ranged from 0.55 [95% confidence interval (CI): 0.51-0.60] to 0.67 (95% CI: 0.61-0.72), with high specificity (72.3%-99.2%) and low sensitivity (4.0%-49.6%). Four multidimensional instruments had much higher sensitivity (20.9%-49.6% versus 4.0%-11.7%) than three purely physical dimensional instruments. Overall, the Frailty Index was more accurate than some instruments in predicting incident outcomes, while several self-report instruments had comparable predictive accuracy to the Frailty Index for all (FRAIL Scale) or some (Groningen Frailty Indicator and Tilburg Frailty Indicator) of the incident outcomes.
Conclusions
All frailty instruments have inadequate predictive accuracy for short-term outcomes among community-dwelling older adults. The Frailty Index roughly performs better but self-report instruments are comparable to the Frailty Index for all or some of the outcomes. An accurate frailty instrument needs to be developed, and the simple self-report instruments could be used temporarily as practical and efficient tools in primary care.
Objectives
Frailty increases the risks of hospitalization, institutionalization, and death. Our objective was to study the effects of home-based physical exercise on the number of days spent at home among pre-frail and frail persons, versus usual care. In addition, utilization and costs of health care and social services, cost-effectiveness, and health-related quality-of-life (HRQoL) were explored.
Design
Randomized controlled trial, with year-long supervised exercise for 60 minutes twice a week versus usual care. Follow-up for 24 months after randomization.
Setting and Participants
A sample of 299 home-dwelling persons in South Karelia, Finland. Main inclusion criteria: ≥65 years, meeting at least 1 of the frailty phenotype criteria, Mini-Mental State Examination score ≥17.
Methods
Primary outcome, days spent at home over 24 months, was calculated deducting days in inpatient care, in nursing homes, and days after death. HRQoL was assessed (15D questionnaire) at baseline and at 3, 6, and 12 months. Utilization data were retrieved from medical records.
Results
The participants' mean age was 82.5 (SD 6.3), 75% were women, 61% were pre-frail and 39% frail. After 24 months, there was no difference between groups in days spent at home [incidence rate ratio 1.03; 95% confidence interval (CI) 0.98–1.09]. After 12 months, the costs per person-year were 1.60-fold in the exercise group (95% CI 1.23–1.98), and after 24 months, 1.23-fold (95% CI 0.95–1.50) versus usual care. Over 12 months, the exercise group gained 0.04 quality-adjusted life-years and maintained the baseline 15D level, while the score in the usual care group deteriorated (P for group <.001, time 0.002, interaction 0.004).
Conclusions and Implications
Physical exercise did not increase the number of days spent at home. Exercise prevented deterioration of HRQoL, and in the frail subgroup, all intervention costs were compensated with decreased utilization of other health care and social services over 24 months.
Objective:
To examine the effects of a multicomponent frailty prevention program in community-dwelling older persons with prefrailty.
Design:
A randomized controlled trial.
Setting:
A community elderly center in Hong Kong.
Participants:
Persons aged ≥50 years who scored 1-2 on a simple frailty questionnaire (FRAIL) METHODS: Participants (n = 127) were randomly assigned to a 12-week multicomponent frailty prevention program (exercise, cognitive training, board game activities) or to a wait-list control group. The primary outcomes were FRAIL scores, frailty status, and a combined frailty measure including subjective (FRAIL total score) and objective (grip strength, muscle endurance, balance, gait speed) measures. The secondary outcomes were verbal fluency assessed by dual-task gait speed, attention and memory assessed by digit span task, executive function assessed by the Frontal Assessment Battery, self-rated health, and life satisfaction. Assessments were conducted at baseline and at week 12.
Results:
The mean age of the participants was 62.2 years, and 88.2% were women. At week 12, the FRAIL score had decreased in the intervention group (-1.3, P < .001) but had increased in the control group (0.3, P < .01) (between-group differences P < .001). In addition, 83.3% and 1.6% of the intervention and control groups, respectively, had reversed from prefrailty to robust phenotype (between-group differences P < .001). Participants in the intervention group also had a greater reduction in the combined frailty score and greater improvements in muscle endurance, balance, verbal fluency, attention and memory, executive function, and self-rated health than those in the control group (all P < .05). There were no significant differences between the groups with respect to grip strength, gait speed, and life satisfaction.
Conclusions and implications:
The multicomponent frailty prevention program reduced frailty and improved physical and cognitive functions, and self-rated health in community-dwelling older persons with prefrailty. Findings can provide insights into the consideration of incorporating frailty prevention programs into the routine practice of community elderly services.
Objective:
To cross-culturally adapt and test the FRAIL scale in Chinese community-dwelling older adults.
Design:
Cross-sectional study.
Methods:
The Chinese FRAIL scale was generated by translation and back-translation. An urban sample of 1235 Chinese community-dwelling older adults was enrolled to test its psychometric properties, including convergent validity, criterion validity, known-group divergent validity, internal consistency and test-retest reliability.
Results:
The Chinese FRAIL scale achieved semantic, idiomatic, and experiential equivalence. The convergent validity was confirmed by statistically significant kappa coefficients (0.209-0.401, P < .001) of each item with its corresponding alternative measurement, including the 7th item of the Center for Epidemiologic Studies-Depression Scale, the Timed Up and Go test, 4-m walking speed, polypharmacy, and the Short-Form Mini Nutritional Assessment. Using the Fried frailty phenotype as an external criterion, the Chinese FRAIL scale showed satisfactory diagnostic accuracy for frailty (area under the curve = 0.91). The optimal cut-point for frailty was 2 (sensitivity: 86.96%, specificity: 85.64%). The Chinese FRAIL scale had fair agreement with the Fried frailty phenotype (kappa = 0.274, P < .001), and classified more participants into frailty (17.2%) than the Fried frailty phenotype (3.9%). More frail individuals were recognized by the Chinese FRAIL scale among older and female participants than their counterparts (P < .001), respectively. It had low internal consistency (Kuder-Richardson formula 20 = 0.485) and good test-retest reliability within a 7- to 15-day interval (intraclass correlation coefficient = 0.708).
Conclusions:
The Chinese FRAIL scale presents acceptable validity and reliability and can apply to Chinese community-dwelling older adults.
Objective:
Within epidemiology a stepped wedge trial design (i.e. a one-way cross-over trial in which several arms start the intervention at different time points) is increasingly popular as an alternative to a classical cluster randomised controlled trial. Despite this increasing popularity, there is a huge variation in the methods used to analyse data from a stepped wedge trial design.
Study design and setting:
Four linear mixed models were used to analyse data from a stepped wedge trial design on two example datasets. The four methods were chosen because they have been (frequently) used in practice. Method 1 compares all the intervention measurements with the control measurements. Method 2 treats the intervention variable as a time-independent categorical variable comparing the different arms with each other. In method 3 the intervention variable is a time-dependent categorical variable comparing groups with different number of intervention measurements while in Method 4 the changes in the outcome variable between subsequent measurements are analysed.
Results:
Regarding the results in the first example dataset. Method 1 and 3 showed a strong positive intervention effect, which disappeared after adjusting for time. Method 2 showed an inverse intervention effect, while Method 4 did not show a significant effect at all. In the second example dataset, the results were the opposite. Both Method 2 and 4 showed significant intervention effects, while the other two methods did not. For Method 4, the intervention effect attenuated after adjustment for time.
Conclusion:
Different methods to analyse data from a stepped wedge trial design reveal different aspects of a possible intervention effect. The choice of a method partly depends on the type of the intervention and the possible time-dependent effect of the intervention. Furthermore, it is advised to combine the results of the different methods to obtain a interpretable overall result.
Background:
frailty is a state of vulnerability to stressor events. There is uncertainty about the beneficial effects of exercise interventions for older people with frailty. The Home-based Older People's Exercise (HOPE) programme is a 12-week-exercise intervention for older people with frailty designed to improve mobility and function.
Methods:
we tested feasibility of the HOPE programme in a two arm, assessor blind pilot randomised controlled trial (RCT). Eligibility criteria included living at home and receiving case manager care, being housebound or attending day centres in Bradford, UK. Intervention participants received the HOPE programme; control participants received usual care. Objectives were to gather process, resource, management and scientific data to inform the design of a definitive trial. Primary outcome was mobility, measured using the timed-up-and-go test (TUGT). Secondary outcomes were activities of daily living, health-related quality of life and depression. Participants were stratified by the baseline TUGT score. Randomisation was by the University of Leeds Clinical Trials Research Unit.
Results:
eighty-four participants were recruited. Forty-five were randomised to intervention and 39 to control. Forty intervention participants and 30 control participants were included in the intention-to-treat analysis. There was a non-significant trend towards a clinically important improved outcome in the intervention group (mean adjusted between-group difference in the TUGT 28.6 s, 95% CI -8.5, 65.9 s). There were no differences in secondary outcomes.
Conclusion:
the HOPE trial has provided preliminary evidence that the deterioration in mobility experienced by older people with frailty may be reduced through a 12-week-exercise intervention. The pilot trial has provided the necessary data to design a future definitive RCT.Trial registration and date of first participant randomisation.Current Controlled Trials: International Standard Randomised Controlled Trial Number ISRCTN57066881. Date of trial registration 19/05/2010. Date of first participant randomisation 15/07/2010.
The health action process approach (HAPA) is attracting increasing interest from researchers who want to predict, explain, and change health‐related behaviors. The main aim of this commentary is to examine the causal structure of the continuum version of the HAPA (HAPA‐C), and, in particular, to consider the implications of this structure for the claim that the theory helps to bridge the intention–behavior gap. The article discusses, in turn, mediators of the intention–behavior relationship, additional proximal determinants of behavior, moderators of the intention–behavior relationship and implications for intervention. The commentary may contribute to a better understanding of the HAPA‐C and to its further development.
L’Approche des Processus d’Action en faveur de la Santé (HAPA) suscite de plus en plus d’intérêt de la part des chercheurs qui souhaitent prédire, expliquer et modifier les comportements relatifs à la santé. L’objet de ce commentaire est l’examen de la structure causale de la version continuum de l’HAPA (HAPA‐C) et, en particulier, de prendre en considération les implications de cette structure dans la prétention de la théorie à combler le fossé intention–comportement. L’article aborde successivement les médiateurs de la relation intention–comportement, les déterminants immédiats additionnels de la conduite, les modérateurs de la relation intention–comportement et les retombées pour les interventions. Ce commentaire peut contribuer à une meilleure compréhension de l’HAPA‐C et à son futur développement.
Planning is regarded as highly valuable in the process of health behaviour change. It bridges the gap between behavioural intentions and health behaviour. To further develop this concept, a distinction is made between action planning and coping planning. The latter refers to the mental simulation of overcoming anticipated barriers to action. Action planning and coping planning for physical exercise were examined in a longitudinal study with 352 cardiac patients. They were approached during rehabilitation treatment and followed up at two and four months after discharge. Both planning cognitions were psychometrically identified, and it was found that they operated differently in the behavioural change process. Action plans were more influential early in the rehabilitation process, whereas coping plans were more instrumental later on. Participants with higher levels of coping planning after discharge were more likely to report higher levels of exercise four months after discharge. It is suggested to include both kinds of planning in interventions at different stages in health behaviour change. Copyright © 2005 John Wiley & Sons, Ltd.
Clinicians whose practice includes elderly patients need a short, reliable instrument to detect the presence of intellectual impairment and to determine the degree. A 10-item Short Portable Mental Status Questionnaire (SPMSQ), easily administered by any clinician in the office or in a hospital, has been designed, tested, standardized and validated. The standardization and validation procedure included administering the test to 997 elderly persons residing in the community, to 141 elderly persons referred for psychiatric and other health and social problems to a multipurpose clinic, and to 102 elderly persons living in institutions such as nursing homes, homes for the aged, or state mental hospitals. It was found that educational level and race had to be taken into account in scoring individual performance. On the basis of the large community population, standards of performance were established for: 1) intact mental functioning, 2) borderline or mild organic impairment, 3) definite but moderate organic impairment, and 4) severe organic impairment. In the 141 clinic patients, the SPMSQ scores were correlated with the clinical diagnoses. There was a high level of agreement between the clinical diagnosis of organic brain syndrome and the SPMSQ scores that indicated moderate or severe organic impairment.
This article highlights the importance of health behavior change (HBC) theory, and its relevance to rehabilitation research and practice.
An extensive review of HBC-related literature pertinent to rehabilitation was conducted, focusing on the potential impact of these theories and models in enhancing long-term results of rehabilitation with regard to lifestyle change and health promotion, and outlining the benefits of incorporating HBC themes into rehabilitation practice. For our purposes, the HBC concept is based on initiation and maintenance of health behaviors, functioning, wellness, and self-management of chronic conditions or disabilities within an environmental context. While comparing and contrasting three widely known theories of HBC, the contributions of these theories to rehabilitation research and practice are discussed.
Three propositions are put forward: (1) HBC variables should regularly be used as outcome measures in evidence-based rehabilitation research; (2) there should be a better understanding of the role of the rehabilitation provider as a facilitator in eliciting healthy behaviors; and (3) there is a need to expand the HBC concept into a more comprehensive view encompassing a person's functioning within the environmental context.
A conceptual merger between HBC theories and rehabilitation practice can have major implications for individuals with disabilities, their functioning, health, and well-being.
Sample size calculations for stepped wedge and cluster randomised trials: a unified approach
- Hemming