Bespoke technology-based intervention programs to prevent falls in older people

and advance healthy ageing

Presentation by Associate Professor Kim Delbaere

Exercise can reduce falls

• Exercise interventions are the single most effective strategies to reduce the rate of falls (Gillespie et al., 2012)

• Moderately to highly

challenging balance exercises and performed for at least two hours a week over a 6-month period (Sherrington et al., 2008)

• Falls reductions by 42%

(Sherrington et al., 2008)

Problem: Adherence to exercise interventions

• Problem : adherence to exercise interventions • On average, by 12 months, half of community-dwelling

older people are likely to be adhering to trial interventions. (Nyman and Victor, 2012)

• Average attrition rate • After 1 year: 52% (range 43-61) (Simek et al., 2012)

• After 2 years: 65% (Campbell et al., 1999)

• Why low adherence?

(Yardley et al., 2006)

No time… too busy

No motivation…

The weather…

No transport…

Not sure what to do…

How can we maximising long-term adherence?

• Evidence from surveys and systematic reviews: • Older people prefer home-based exercise programs

• Especially in those older and more socially deprived people who are at the highest risk of falling. (Yardley et al., 2008)

• Inclusion of balance training is associated with better adherence in home-based exercise programs (Simek et al., 2012)

• Evidence from health belief model:

• Education: People who understand that exercising for more than 2 hours per week is an effective strategy to reduce their risk of falls are more likely to adopt these recommendation

Technology can help to deliver this better.

Designing an exercise program

• Programs need to be enjoyable and stimulating – This can be achieved by providing a variety of different exercises tailored to the

individual to ensure exercises are challenging yet attainable.

• Exercises designed to improve outcomes significant to older people. – This can be achieved by carefully designing the exercise to include evidence-based

exercise prescription aimed at improving physical abilities, preventing falls and maintaining independence.

• Inclusion of behaviour change strategies to increase exercise adherence. – Examples of are feedback, self-monitoring, planning of activities, goal setting, and

educational material on the benefits of regular exercise.

• Technologies must be designed in ways that are accessible to older people regardless of their previous technology exposure. – Examples are: intuitive user-interface, high colour contrasts, large font, big buttons

with on screen instructions.

Designing an exercise program

Three examples of technology-based interventions

i. SureStep: step mat technology ii. iStoppFalls: Kinect technology iii. StandingTall: iPad technology

SureStep is an interactive, functional and task-specific step training program, requiring both cognitive & motor activity involving balance control.

– stepping onto electronic mat to interact with a computer interface – videogame technology to deliver additional cognitive task on the screen

Fall prevention – SureStep

StepMania

StepTrails

StepTetris

Stepper

Rapid stepping

Complex stepping

Visuo-spatial ability

Attention & set shifting

Fall prevention – SureStep

• Dose: 120 minutes per week

• Intensity: moderately to highly challenging

• Exercises: StepMania, Tetris, Trails. – The motor (stepping) component trains people to take quick

and accurate lateral and anterior-posterior steps. – The cognitive component, delivered as fun ‘games’, trains

specific executive functions including working memory, visuo-spatial skills, dual-tasking, inhibition and attention.

• Progressions: combination of step training and video games makes it possible to increase complexity and engagement by adding challenging cognitive tasks. – Weight shifting, increased speed – Inhibition, cognitive dual task component

Fall prevention – SureStep

Fall prevention – SureStep

Schoene D, et al. 2014. PlosOne (in preparation)

Adherence

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StepMania Stepper StepTertris StepTrails

Low adherenceRecommended adherence

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Time played intervention in minutes N Mean SD Control Group 42 0 0 Zero adherence 6 0 0 Low adherence 16 326 290 Recommended adherence 17 2547 2681

05

101520253035404550

Control Group Low adherence High adherence

Stepping performance

Physical function and attention

Executive functioning

Perc

enta

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hang

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) Fall prevention – SureStep

(N=9) (N=30)

• Improvements in physical function – Overall improvements in stepping performance – PPA in people with lower baseline score and low adherers

• Improvements in cognitive function

– Overall improvements in processing speed, executive functioning, divided attention

– Larger improvements in less complex cognitive function in low adherers

– Larger improvements in more complex cognitive function in high adherers

• Hypothesis: Progression through the games increased cognitive challenges, but less physical challenges.

Fall prevention – SureStep

Three examples of technology-based interventions

i. SureStep: step mat technology ii. iStoppFalls: Kinect technology iii. StandingTall: iPad technology

Fall prevention – iStoppFalls

• Dose: 180 minutes per week

• Intensity: moderately to highly challenging

• Exercises: hills n skills, bistro game, walking – Balance games combine three key elements of balance

training: weight shifting, knee bending and stepping – Strength exercises are based on a validated program (Otago)

• Progressions: – Balance games:

• reducing upper limb support, narrowing base of feet support, • including movement of arms (e.g. reaching), • increasing the difficulty of the cognitive component

– Strength exercises: increasing weights

Fall prevention – iStoppFalls

Multi-centre Randomized Controlled Trial Exclusion criteria: • Severe Diseases: e.g.

cardiovascular, neurologic, orthopedic, cancer.

• Impaired cognition • vision impairment

Inclusion criteria: • Age 65+, • Able to walk without

aids; • Independent Living • Internet Access • HDMI-TV

Gschwind, et al. 2014. BMC geriatrics 14 (1), 91

Recruitment through oral presentation, leaflets, newspaper

Initial contact via phone

Informed consent and baseline assessments

Randomization (n = 160)

16 week iStoppFalls exercise intervention

Assessments post intervention

Intervention Control

Germany Intervention (N=31)

Control (N=30)

Spain Intervention (N=22)

Control (N=20)

Australia Intervention (N=29)

Control (N=28)

• Dose: – Requested: 180 minutes per week – Average achieved: 44 minutes per week [median=12h, IQR=22]

• Exercises:

– Balance games: • Requested: 120 minutes per week • Average achieved: 15 minutes per week [median = 4 hours,

IQR = 7] – Strength exercises:

• Requested: 60 minutes per week • Average achieved: 30 minutes per week [median = 8 hours,

IQR = 13]

Feasibility: adherence

Gschwind, et al. 2014. Eur Review Phys Act Ageing

Pre-planned subgroup analysis – adherence (90 min)

• Feasibility – The iStoppFalls exercise program is feasible in terms of

safety for older people – More work is needed to optimize the usability of the

program to increase adherence.

• Effectiveness – intention-to-treat : the 16-week iStoppFalls exercise

program reduced physiological fall risk – subgroup analyses: intervention participants with

better adherence also improved in postural sway, stepping reaction and executive function.

Conclusion

Gschwind, et al. 2014. Eur Review Phys Act Ageing

Three examples of technology-based interventions

i. SureStep: step mat technology ii. iStoppFalls: Kinect technology iii. StandingTall: iPad technology

Balance exercises

Design for and with older adults

• Font size and colour contrast

• exercise videos to enhance a better understanding of the exercises,

• voice over to facilitate reading

• Calendar and alert features to facilitate adherence to exercise program

Focus group

All participants approved the design of “Standing Tall” and highlighted that the exercise videos would facilitate the understanding of the exercises as well as assist to perform the exercises correctly. Participants also emphasized the need for individualized exercise programs like “Standing Tall” where the exercises are progressed according to their own abilities.

Development

• Dose: 120 minutes per week

• Intensity: moderately to highly challenging

• Exercises: combining three key elements of balance training: weight shifting, knee bending and stepping

• Progressions: – reducing upper limb support, narrowing base of feet

support, – including movement of arms (e.g. reaching), – Step, compliant surface – increasing the difficulty by adding combinations

Fall prevention

Start session; select session length Preview screen Instructional video Exercise screen

Rating of each exercise

Session completed; return to main menu

Example of the flow of an exercise session

Standing Tall Features

Unique activity planner Calendar • Allows you to plan in your exercises • Option to set alarm to remind you it is time to exercise • Keeps track of how many minutes of exercises you still

need to do

Goal setting • Short-term goal: How to start new exercise routine? • Intermediate goal: How to main exercise routine? • Long-term benefits: Other tasks or activities you want

to improve?

Randomised Control Trial

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367746

Adherence

Participants reached a median of 74.4 minutes of exercise per week, and 33.3 hours (SD 78.4) in total, which is equivalent to 74% of the recommended dose over the first six months of the study.

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Med

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inut

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Weeks Median weekly exercise adherence Recommended weekly exercise dose

Adherence

Participants reached a median of 74.4 minutes of exercise per week, and 33.3 hours (SD 78.4) in total, which is equivalent to 74% of the recommended dose over the first six months of the study.

% o

f par

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Average weekly exercise adherence

0%

5%

10%

15%

20%

25%

> 120 min 100 - 120 min 70 -99 min 30 - 69 min < 30 min drop-out

Participant ratings of four items: (a) enjoyment, (b) continuing use, (c) user-friendliness, (d) overall rating of the Standing Tall program. Data collected using the user experience questionnaire at the 6 month re-assessment point.

I enjoy using StandingTall to

exercise my balance I see myself using

StandingTall for 2h/wk

I rate user-friendliness of

StandingTall as: Overall, I would rate

StandingTall as:

Examples of perceived benefits of using the Standing Tall program

‘I can now stand on one leg, I couldn’t before.’ Patricia, 85 year old female

‘It helps me to exercise regularly.’ June, 71 year old female

‘I am more confident about not falling.’ Christine, 73 year old female

‘It has improved my balance and developed some muscles that I didn’t know I had, for example, the muscles used in standing on my toe and heels. Also, it has motivated me to exercise more regularly.’

Paul, 75 year old male

‘I am walking longer distances with more confidence and without my stick – but I still like to know it’s not too far from me.’

Fay, 89 year old female

‘I feel more confident and I think there has been a general improvement in my health both physically and mentally.’

Kenneth, 83 year old male

‘I do more exercise than I would otherwise.’ Bev, 71 year old female

‘I think it has helped me to be conscious about my balance and also to exercise regularly.’

Beverly, 70 year old female

‘I feel a bit fitter, feel pleased at the discipline, even just having the framework there. I’ve noticed I’m motivated to do better at the exercises.’

Grace, 77 year old female

‘I am now doing 2 hours of exercise per week in my home, this was not the case previously.’

Robert, 72 year old male

Conclusion

• Types of technology: – Mobile technology: e.g iPad – Videogame technology: e.g. dance mat, Kinect

• Findings: – Feasible to deliver exercise programs in the homes of older adults – Effective at improving balance, reducing fall risk – Effective at improving cognitive function

• Some advantages: – Commercially-available = inexpensive technologies – Enables greater choice in preferred exercise options, increased

convenience and greater level of engagement. – Automated tailoring and progression. – Monitoring of progress and adherence to the program – Immediate performance feedback – Highly accessible to large populations, including people living in regional

and remote Australia

Fall prevention – advantages technology

• More R & D necessary for implementation: – fail-proofing, simplifying, limiting need for support – Large teams, funding – How can we work together with industry?

• More research necessary to see long-term effects:

– Can we prevent falls? – Is it cost-effective? – Will people use it for longer periods?

• Implementation studies needed to trial in clinical practice:

– Information for feedback to health care practitioners, older adults – Large amounts of data: storing? – Data privacy (e.g. adherence to intervention)

Using technology – future work

For further questions Contact: Kim Delbaere k.delbaere@neura.edu.au