Publications by authors named "Lillemor Lundin-Olsson"

64 Publications

Sarcopenic Obesity in Africa: A Call for Diagnostic Methods and Appropriate Interventions.

Front Nutr 2021 16;8:661170. Epub 2021 Apr 16.

Health Sciences and Sport, University of Stirling, Stirling, United Kingdom.

This perspective aims to highlight the lack of current knowledge on sarcopenic obesity in Africa and to call for diagnostic methods and appropriate interventions. Sarcopenic obesity has been defined as obesity that occurs in combination with low muscle mass and function, which is typically evident in older adults. However, there has been no clear consensus on population-specific diagnostic criterion, which includes both gold-standard measures that can be used in a more advanced health care system, and surrogate measures that can be used in low-income settings with limited resources and funding. Importantly, low and middle-income countries (LMICs) across Africa are in an ongoing state of economic and social transition, which has contributed to an increase in the aging population, alongside the added burden of poverty, obesity, and associated co-morbidities. It is anticipated that alongside the increased prevalence of obesity, these countries will further experience an increase in age-related musculoskeletal diseases such as sarcopenia. The developmental origins of health and disease (DOHaD) approach will allow clinicians and researchers to consider developmental trajectories, and the influence of the environment, for targeting high-risk individuals and communities for treatment and/or prevention-based interventions that are implemented throughout all stages of the life course. Once a valid and reliable diagnostic criterion is developed, we can firstly assess the prevalence and burden of sarcopenic obesity in LMICs in Africa, and secondly, develop appropriate and sustainable interventions that target improved dietary and physical activity behaviors throughout the life course.
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http://dx.doi.org/10.3389/fnut.2021.661170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085278PMC
April 2021

Understanding factors associated with sarcopenic obesity in older African women from a low-income setting: a cross-sectional analysis.

BMC Geriatr 2021 04 14;21(1):247. Epub 2021 Apr 14.

Health Sciences and Sport, University of Stirling, Stirling, Scotland.

Background: High rates of food insecurity, obesity and obesity-related comorbidities in ageing South African (SA) women may amplify the risk of developing sarcopenic obesity. This study aimed to investigate the prevalence and correlates of sarcopenic obesity and its diagnostic components [grip strength, appendicular skeletal muscle mass (ASM) and body mass index (BMI)] in older SA women from a low-income setting.

Methods: This cross-sectional study recruited black SA women between the ages of 60-85 years (n = 122) from a low-income community. Testing included a fasting blood sample (markers of cardiometabolic risk, HIV), whole body and regional muscle and fat mass (dual-energy absorptiometry x-ray), anthropometry, blood pressure, functional movement tests, current medication use, demographic and health questionnaires, physical activity (PA; accelerometery), household food insecurity access scale, and a one-week quantified food frequency questionnaire. Foundation for the National Institutes of Health (FNIH) criteria (grip strength and ASM, adjusted for BMI) were used to classify sarcopenia. Participants with sarcopenia alongside a BMI of > 30.0 kg/m were classified as having sarcopenic obesity. Prevalence using other criteria (European Working Group on Sarcopenia in Older People, Asian Working Group for Sarcopenia and the International Working Group for Sarcopenia) were also explored.

Results: The prevalence of sarcopenia was 27.9%, which comprised of sarcopenia without obesity (3.3%) and sarcopenic obesity (24.6%). Other classification criteria showed that sarcopenia ranged from 0.8-14.7%, including 0.8-9.8% without obesity and 0-4.9% with sarcopenic obesity. Using multivariate-discriminant analysis (OPLS-DA) those with sarcopenic obesity presented with a descriptive profile of higher C-reactive protein, waist circumference, food security and sedentary time than women without sarcopenic obesity (p = 0.046). A similar profile described women with low BMI-adjusted grip strength (p < 0.001).

Conclusions: The majority of women with sarcopenia were also obese (88%). We show a large discrepancy in the diagnostic criteria and the potential for significantly underestimating the prevalence of sarcopenia if BMI is not adjusted for. The main variables common to women with sarcopenic obesity were higher food security, lower PA and chronic inflammation. Our data highlights the importance of addressing obesity within these low-income communities to ensure the prevention of sarcopenic obesity and that quality of life is maintained with ageing.
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http://dx.doi.org/10.1186/s12877-021-02132-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048063PMC
April 2021

Falls and Fear of Falling in Shunted Idiopathic Normal Pressure Hydrocephalus-The Idiopathic Normal Pressure Hydrocephalus Comorbidity and Risk Factors Associated With Hydrocephalus Study.

Neurosurgery 2021 Jun;89(1):122-128

Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.

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.
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http://dx.doi.org/10.1093/neuros/nyab094DOI Listing
June 2021

Measurement error of the Mini-Mental State Examination among individuals with dementia that reside in nursing homes.

Eur J Ageing 2021 Mar 3;18(1):109-115. Epub 2020 Jun 3.

Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden.

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 ( = 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 ( = 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.
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http://dx.doi.org/10.1007/s10433-020-00572-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925761PMC
March 2021

Exercise effects on backward walking speed in people with dementia: A randomized controlled trial.

Gait Posture 2021 03 13;85:65-70. Epub 2021 Jan 13.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå University, 901 87, Umeå, Sweden.

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.
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http://dx.doi.org/10.1016/j.gaitpost.2020.12.028DOI Listing
March 2021

Proposals for continued research to determine older adults' falls risk.

J Frailty Sarcopenia Falls 2020 Dec 1;5(4):89-91. Epub 2020 Dec 1.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Early detection of older adults with an increased risk of falling could enable early onset of preventative measures. Currently used fall risk assessment tools have not proven sufficiently effective in differentiating between high and low fall risk in community-living older adults. There are a number of tests and measures available, but many timed and observation-based tools are performed on a flat floor without interaction with the surrounding. To improve falls prediction, measurements in other areas that challenge mobility in dynamic conditions and that take a persons' own perception of steadiness into account should be further developed and evaluated as single or combined measures. The tools should be easy to apply in clinical practice or used as a self-assessment by the older adults themselves.
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http://dx.doi.org/10.22540/JFSF-05-089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711736PMC
December 2020

Older adults' preferences for, adherence to and experiences of two self-management falls prevention home exercise programmes: a comparison between a digital programme and a paper booklet.

BMC Geriatr 2020 06 15;20(1):209. Epub 2020 Jun 15.

Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Umeå, Sweden.

Background: Fall prevention exercise programmes are known to be effective, but access to these programmes is not always possible. The use of eHealth solutions might be a way forward to increase access and reach a wider population. In this feasibility study the aim was to explore the choice of programme, adherence, and self-reported experiences comparing two exercise programmes - a digital programme and a paper booklet.

Methods: A participant preference trial of two self-managed fall prevention exercise interventions. Community-dwelling adults aged 70 years and older exercised independently for four months after one introduction meeting. Baseline information was collected at study start, including a short introduction of the exercise programme, a short physical assessment, and completion of questionnaires. During the four months intervention period, participants self-reported their performed exercises in an exercise diary. At a final meeting, questionnaires about their experiences, and post-assessments, were completed. For adherence analyses data from diaries were used and four subgroups for different levels of participation were compared. Exercise maintenance was followed up with a survey 12 months after study start.

Results: Sixty-seven participants, with mean age 77 ± 4 years were included, 72% were women. Forty-three percent chose the digital programme. Attrition rate was 17% in the digital programme group and 37% in the paper booklet group (p = .078). In both groups 50-59% reported exercise at least 75% of the intervention period. The only significant difference for adherence was in the subgroup that completed ≥75% of exercise duration, the digital programme users exercised more minutes per week (p = .001). Participants in both groups were content with their programme but digital programme users reported a significantly higher (p = .026) degree of being content, and feeling supported by the programme (p = .044). At 12 months follow-up 67% of participants using the digital programme continued to exercise regularly compared with 35% for the paper booklet (p = .036).

Conclusions: Exercise interventions based on either a digital programme or a paper booklet can be used as a self-managed, independent fall prevention programme. There is a similar adherence in both programmes during a 4-month intervention, but the digital programme seems to facilitate long-term maintenance in regular exercise.

Trial Registration: ClinTrial: NCT02916849.
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http://dx.doi.org/10.1186/s12877-020-01592-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294667PMC
June 2020

Neither Timed Up and Go test nor Short Physical Performance Battery predict future falls among independent adults aged ≥75 years living in the community.

J Frailty Sarcopenia Falls 2020 Jun 1;5(2):24-30. Epub 2020 Jun 1.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Objectives: Previous research has shown that balance and gait difficulties are predictors of falls. The aim of this study was to evaluate the predictive validity of two tools reporting on balance and gait among older community-living adults independent in personal activities of daily living (p-ADL).

Methods: Prospective study design. Baseline assessment included the Timed Up and Go test (TUG) and the Short Physical Performance Battery (SPPB). Following baseline, falls were recorded monthly for one year by 202 participants (70.1% women) who were independent in p-ADL, and at least 75 years old (79.2±3.5). ROC-curves were made and AUC were calculated.

Results: Forty-seven percent of the participants reported falls. AUCs calculated for TUG were 0.5 (95%CI: 0.5-0.6) for those with at least one fall, and 0.5 (95% CI: 0.5-0.6) for recurrent fallers. Corresponding figures for SPPB were 0.5 (95% CI: 0.5-0.6) and 0.5 (95% CI: 0.5-0.6).

Conclusion: This study does not support a recommendation to use the Timed Up and Go test or the Short Physical Performance Battery as tools for the identification of fall-prone persons among older adults living in the community. These results reinforce the need for further research into appropriate tools for identifying independent but fall-prone older adults.
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http://dx.doi.org/10.22540/JFSF-05-024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272775PMC
June 2020

Effectiveness of a self-managed digital exercise programme to prevent falls in older community-dwelling adults: study protocol for the Safe Step randomised controlled trial.

BMJ Open 2020 05 17;10(5):e036194. Epub 2020 May 17.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Introduction: Exercise interventions have a strong evidence base for falls prevention. However, exercise can be challenging to implement and often has limited reach and poor adherence. Digital technology provides opportunities for both increased access to the intervention and support over time. Further knowledge needs to be gained regarding the effectiveness of completely self-managed digital exercise interventions. The main objective of this study is to compare the effectiveness of a self-managed digital exercise programme, Safe Step, in combination with monthly educational videos with educational videos alone, on falls over 1 year in older community-dwelling adults.

Methods And Analysis: A two-arm parallel randomised controlled trial will be conducted with at least 1400 community-living older adults (70+ years) who experience impaired balance. Participants will be recruited throughout Sweden with enrolment through the project website. They will be randomly allocated to either the Safe Step exercise programme with additional monthly educational videos about healthy ageing and fall prevention, or the monthly education videos alone. Participants receiving the exercise intervention will be asked to exercise at home for at least 30 min, 3 times/week with support of the Safe Step application. The primary outcome will be rate of falls (fall per person year). Participants will keep a fall calendar and report falls at the end of each month through a digital questionnaire. Further assessments of secondary outcomes will be made through self-reported questionnaires and a self-test of 30 s chair stand test at baseline and 3, 6, 9 and 12 months after study start. Data will be analysed according to the intention-to-treat principle.

Ethics And Dissemination: Ethical approval was obtained by The Regional Ethical Review Board in Umeå (Dnr 2018/433-31). Findings will be disseminated through the project web-site, peer-reviewed journals, national and international conferences and through senior citizen organisations' newsletters.

Trial Registration Number: NCT03963570.
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http://dx.doi.org/10.1136/bmjopen-2019-036194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239551PMC
May 2020

'Managing pieces of a personal puzzle' - Older people's experiences of self-management falls prevention exercise guided by a digital program or a booklet.

BMC Geriatr 2019 02 18;19(1):43. Epub 2019 Feb 18.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: Exercise is effective in order to prevent falls in community-dwelling older people. Self-management programs have the potential to increase access and reduce costs related to exercise-based fall prevention. However, information regarding older people's views of participating in such programs is needed to support implementation. The aim of this study was to explore older people's experiences of a self-management fall prevention exercise routine guided either by a digital program (web-based or mobile) or a paper booklet.

Methods: This qualitative study was part of a feasibility study exploring two completely self-managed exercise interventions in which the participants tailored their own program, guided either by a digital program or a paper booklet. Individual face-to-face semi-structured interviews were conducted with a purposeful sample of 28 participants (18 women), mean age 76 yrs. Qualitative content analysis was used to analyse the data.

Results: Self-managing and self-tailoring these exercise programs was experienced as 'Managing pieces of a personal puzzle'. To independently being able to create a program and manage exercise was described in the categories 'Finding my own level' and 'Programming it into my life'. The participants experienced the flexibility and independence provided by completely self-managed exercise as positive and constructive although it required discipline. Furthermore, different needs and preferences when managing their exercise were described, as well as varying sources of motivation for doing the exercise, as highlighted in the category 'Defining my source of motivation'. The category 'Evolving my acquired knowledge' captures the participants' views of building their competence and strategies for maintenance of the exercise. It describes a combined process of learning the program and developing reflection, which was more clearly articulated by participants using the digital program.

Conclusions: This study provides new knowledge regarding experiences, preferences and motivations of older people to engage in home-based self-managed fall prevention exercise. They expressed both a capability and willingness to independently manage their exercise. A digital program seems to have strengthened the feeling of support while creating their own exercise program and tailoring it to their preferences and circumstances, which might therefore create better opportunities for adoption and adherence in the long term.
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http://dx.doi.org/10.1186/s12877-019-1063-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378707PMC
February 2019

The Effects of Exercise on Falls in Older People With Dementia Living in Nursing Homes: A Randomized Controlled Trial.

J Am Med Dir Assoc 2019 Jul 28;20(7):835-842.e1. Epub 2018 Nov 28.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden; Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden.

Objectives: To investigate exercise effects on falls in people with dementia living in nursing homes, and whether effects were dependent on sex, dementia type, or improvement in balance. A further aim was to describe the occurrence of fall-related injuries.

Design: A cluster-randomized controlled trial.

Setting And Participants: The Umeå Dementia and Exercise study was set in 16 nursing homes in Umeå, Sweden and included 141 women and 45 men, a mean age of 85 years, and with a mean Mini-Mental State Examination score of 15.

Intervention: Participants were randomized to the high-intensity functional exercise program or a seated attention control activity; each conducted 2-3 times per week for 4 months.

Measures: Falls and fall-related injuries were followed for 12 months (after intervention completion) by blinded review of medical records. Injuries were classified according to severity.

Results: During follow-up, 118 (67%) of the participants fell 473 times in total. At the interim 6-month follow-up, the incidence rate was 2.7 and 2.8 falls per person-year in exercise and control group, respectively, and at 12-month follow-up 3.0 and 3.2 falls per person-year, respectively. Negative binomial regression analyses indicated no difference in fall rate between groups at 6 or 12 months (incidence rate ratio 0.9, 95% confidence interval (CI) 0.5-1.7, P = .838 and incidence rate ratio 0.9, 95% CI 0.5-1.6, P = .782, respectively). No differences in exercise effects were found according to sex, dementia type, or improvement in balance. Participants in the exercise group were less likely to sustain moderate/serious fall-related injuries at 12-month follow-up (odds ratio 0.31, 95% CI 0.10-0.94, P = .039).

Conclusions/implications: In older people with dementia living in nursing homes, a high-intensity functional exercise program alone did not prevent falls when compared with an attention control group. In high-risk populations, in which multimorbidity and polypharmacy are common, a multifactorial fall-prevention approach may be required. Encouraging effects on fall-related injuries were observed, which merits future investigations.
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http://dx.doi.org/10.1016/j.jamda.2018.10.009DOI Listing
July 2019

Motivation to participate in high-intensity functional exercise compared with a social activity in older people with dementia in nursing homes.

PLoS One 2018 14;13(11):e0206899. Epub 2018 Nov 14.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: Motivation to participate in exercise among people with dementia has not been well studied. The symptoms of dementia, including apathy, may lead to low motivation to participate in exercise. The aim of this study was to evaluate the motivation of older people with dementia to participate in a high-intensity exercise program compared with motivation of those participating in a social group activity.

Methods: The Umeå Dementia and Exercise Study (UMDEX) was a cluster-randomized controlled intervention trial including 186 people (mean age; 85, 75% female) with dementia in nursing homes. Participants were randomized to participate in the High-Intensity Functional Exercise (HIFE) Program (n = 93) or a seated social group activity (n = 93). The activities were conducted in groups of 3-8 participants for 45 minutes, five times per two-week period, for 4 months (40 sessions in total). Participants' motivation to go to and during activity sessions were assessed by the activity leaders and nursing homes staff using a five-point Likert scale. Data were analyzed using cumulative link mixed models.

Results: Motivation was high or very high during 61.0% of attended sessions in the exercise group and 62.6% in the social activity group. No overall significant difference between groups was observed, but motivation increased over time in the exercise group and decreased in the social activity group (p < 0.05). Motivation during the sessions was significantly higher than motivation to go to the sessions, especially in the exercise group [OR 2.39 (95% CI 2.38-2.40) and 1.50 (95% CI 1.32-1.70), respectively].

Conclusions: Among older people with dementia in nursing homes, motivation to participate in a high-intensity functional exercise program seems to be high, comparable to motivation to participate in a social activity, and increase over time. Since motivation during activity sessions was higher than motivation to go to sessions the promotion of strategies to encourage people with dementia to join exercise groups is of great importance.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206899PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235314PMC
April 2019

Gender Perspective on Older People's Exercise Preferences and Motivators in the Context of Falls Prevention: A Qualitative Study.

Biomed Res Int 2018 18;2018:6865156. Epub 2018 Jul 18.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: Several factors have previously been identified to positively influence the uptake and adherence for fall prevention exercise programmes. There is, however, a lack of studies investigating if men and women differ in their views and preferences for fall prevention exercises.

Aim: To explore exercise preferences and motivators of older community-dwelling women and men in the context of falls prevention from a gender perspective.

Methods: Workshops including multistage focus group discussions were conducted with 18 older community-dwelling people with and without history of falls. Participants were purposively selected and divided into two groups. Each group met on six occasions over a period of five months. Participatory and Appreciative Action and Reflection methodology was used to guide the discussions. A qualitative content analysis approach was used in the analysis.

Results: Older participants had many diverse preferences and confirmed that individually tailored exercise, in terms of mode, intensity, challenge, and social context, is important. Moreover, important factors for exercise adherence and maintenance included the experience of individual confirmation; different spirit lifters to increase enjoyment; and personal tricks to maintain exercise routines. The individual differences within genders were more diverse than the differences between women and men.

Conclusion: Exercise interventions to prevent falls should be individually tailored, based on the specific needs and preferences of the older participant, and do not appear to require gender specific approaches. To increase adherence, intrinsic motivation for exercise may be encouraged by competence enhancing confirmations, energizing spirit lifters, and practical tips for exercise maintenance. The study provides an awareness about women's and men's preferences for fall prevention exercises, and this information could be used as guidance in designing inclusive exercise interventions.
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http://dx.doi.org/10.1155/2018/6865156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077582PMC
December 2018

Experiences of older people with dementia participating in a high-intensity functional exercise program in nursing homes: "While it's tough, it's useful".

PLoS One 2017 17;12(11):e0188225. Epub 2017 Nov 17.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

The objective of the study was to describe the views and experiences of participation in a high-intensity functional exercise (HIFE) program among older people with dementia in nursing homes. The study design was a qualitative interview study with 21 participants (15 women), aged 74-96, and with a Mini-Mental State Examination score of 10-23 at study start. The HIFE-program comprises exercises performed in functional weight-bearing positions and including movements used in everyday tasks. The exercise was individually designed, supervised in small groups in the nursing homes and performed during four months. Interviews were performed directly after exercise sessions and field notes about the sessions were recorded. Qualitative content analysis was used for analyses. The analysis revealed four themes: Exercise is challenging but achievable; Exercise gives pleasure and strength; Exercise evokes body memories; and Togetherness gives comfort, joy, and encouragement. The intense and tailored exercise, adapted to each participant, was perceived as challenging but achievable, and gave pleasure and improvements in mental and bodily strength. Memories of previous physical activities aroused and participants rediscovered bodily capabilities. Importance of individualized and supervised exercise in small groups was emphasized and created feelings of encouragement, safety, and coherence. The findings from the interviews reinforces the positive meaning of intense exercise to older people with moderate to severe dementia in nursing homes. The participants were able to safely adhere to and understand the necessity of the exercise. Providers of exercise should consider the aspects valued by participants, e.g. supervision, individualization, small groups, encouragement, and that exercise involved joy and rediscovery of body competencies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0188225PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5693409PMC
December 2017

Cognitive function and walking velocity in people with dementia; a comparison of backward and forward walking.

Gait Posture 2017 10 9;58:481-486. Epub 2017 Sep 9.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden; Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden. Electronic address:

How forward and backward walking, both central to everyday life, relate to cognition are relatively unexplored in people with dementia. This study aimed to investigate if forward and backward walking velocity respectively, associated with global cognition and executive function in people with dementia, and whether the association differed according to walking aid use or dementia type. Using a cross-sectional design, 161 participants (77% women), a mean Mini-Mental State Examination (MMSE) score of 15, and mean age of 85.5years and living in nursing homes were included. Self-paced forward walking (FW) and backward walking (BW) velocity over 2.4m was measured. Global cognitive outcome measurements included MMSE and Alzheimer Disease Assessment Scale - Cognitive subscale (ADAS-Cog). Executive function was measured using Verbal Fluency (VF). In comprehensively adjusted multivariate linear regression analyses, FW was independently associated with VF (p=0.001), but not MMSE (p=0.126) or ADAS-Cog (p=0.818). BW was independently associated with VF (p=0.043) and MMSE (p=0.022), but not ADAS-Cog (p=0.519). Interaction analyses showed that the association between BW velocity and executive function were stronger in participants who walked without a walking aid. No associations differed according to dementia type. In conclusion, executive function appears important to walking velocity, both forward and backward, in people with dementia with mild to moderately severe cognitive impairment. Global cognitive function was associated with backward walking only, perhaps due to it being more challenging. The association between BW velocity and executive function differed according to use of walking aids, which appeared to attenuate the association.
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http://dx.doi.org/10.1016/j.gaitpost.2017.09.009DOI Listing
October 2017

Effects of Exercise on Cognitive Function in Older People with Dementia: A Randomized Controlled Trial.

J Alzheimers Dis 2017 ;60(1):323-332

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: Although physical exercise has been suggested to influence cognitive function, previous exercise studies show inconsistent results in people with dementia.

Objectives: To investigate effects of exercise on cognitive function in people with dementia.

Method: The Umeå Dementia and Exercise (UMDEX) study, a cluster-randomized controlled trial, was set in 16 nursing homes in Umeå, Sweden. One hundred-and-forty-one women and 45 men with dementia; mean age of 85 y and mean Mini-Mental State Examination (MMSE) score of 15, were randomized to a High-Intensity Functional Exercise program or a seated attention control activity. Blinded assessors measured global cognitive function using the MMSE and the Alzheimer's disease Assessment Scale - Cognitive subscale (ADAS-Cog), and executive function using Verbal fluency (VF) at baseline and 4 months (directly after intervention completion), and MMSE and VF at 7 months.

Results: Linear mixed models showed no between-group effects in mean difference from baseline (95% confidence intervals, CI) at 4 months in MMSE (-0.27; 95% CI -1.4 to 0.87, p = 0.644), ADAS-Cog (-1.04, 95% CI -4 to 1.92, p = 0.491), or VF (-0.53, 95% CI -1.42 to 0.35, p = 0.241) or at 7 months in MMSE (-1.15, 95% CI -2.32 to 0.03, p = 0.056) or VF (-0.18, 95% CI -1.09 to 0.74, p = 0.707).

Conclusion: A 4-month, high-intensity functional exercise program had no superior effects on global cognition or executive function in people with dementia living in nursing homes when compared with an attention control activity.
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http://dx.doi.org/10.3233/JAD-170014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611799PMC
May 2018

Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies review.

BMC Geriatr 2017 02 17;17(1):58. Epub 2017 Feb 17.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: To offer fall prevention exercise programs that attract older people of both sexes there is a need to understand both women's and men's views and preferences regarding these programs. This paper aims to systematically review the literature to explore any underlying gender perspectives or gender interpretations on older people's views or preferences regarding uptake and adherence to exercise to prevent falls.

Methods: A review of the literature was carried out using a convergent qualitative design based on systematic searches of seven electronic databases (PubMed, CINAHL, Amed, PsycINFO, Scopus, PEDro, and OTseeker). Two investigators identified eligible studies. Each included article was read by at least two authors independently to extract data into tables. Views and preferences reported were coded and summarized in themes of facilitators and barriers using a thematic analysis approach.

Results: Nine hundred and nine unique studies were identified. Twenty five studies met the criteria for inclusion. Only five of these contained a gender analysis of men's and women's views on fall prevention exercises. The results suggests that both women and men see women as more receptive to and in more need of fall prevention messages. The synthesis from all 25 studies identified six themes illustrating facilitators and six themes describing barriers for older people either starting or adhering to fall prevention exercise. The facilitators were: support from professionals or family; social interaction; perceived benefits; a supportive exercise context; feelings of commitment; and having fun. Barriers were: practical issues; concerns about exercise; unawareness; reduced health status; lack of support; and lack of interest. Considerably more women than men were included in the studies.

Conclusion: Although there is plenty of information on the facilitators and barriers to falls prevention exercise in older people, there is a distinct lack of studies investigating differences or similarities in older women's and men's views regarding fall prevention exercise. In order to ensure that fall prevention exercise is appealing to both sexes and that the inclusion of both men and women are encouraged, more research is needed to find out whether gender differences exists and whether practitioners need to offer a range of opportunities and support strategies to attract both women and men to falls prevention exercise.
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http://dx.doi.org/10.1186/s12877-017-0451-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316178PMC
February 2017

Reach the Person behind the Dementia - Physical Therapists' Reflections and Strategies when Composing Physical Training.

PLoS One 2016 1;11(12):e0166686. Epub 2016 Dec 1.

Department of Community Health and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Dementia is a disease characterized by cognitive impairment and physical decline that worsens over time. Exercise is one lifestyle factor that has been identified as a potential means of reducing or delaying progression of the symptoms of dementia, maximizing function and independence. The purpose of this study was to explore physical therapists' (PTs) experiences and reflections on facilitating high-intensity functional exercise with older people living with dementia, in residential care home settings. The study used a qualitative design based on interviews, individually or in small groups, with seven PTs engaged as leaders in the training of older people with dementia. The interviews were analyzed with a modified Grounded Theory method with focus on constant comparisons. To increase trustworthiness the study used triangulation within investigators and member checking. The core category "Discover and act in the moment-learn over time" reflects how the PTs continuously developed their own learning in an iterative process. They built on previous knowledge to communicate with residents and staff and to tailor the high intensity training in relation to each individual at that time point. The category "Be on your toes" highlights how the PTs searched for sufficient information about each individual, before and during training, by eliciting the person's current status from staff and by interpreting the person's body language. The category "Build a bond with a palette of strategies" describes the importance of confirmation to build up trust and the use of group members and the room to create an interplay between exercise and social interaction. These findings highlight the continuous iterative process of building on existing knowledge, sharing and reflecting, being alert to any alterations needed for individuals that day, communication skills (both with residents and staff) and building a relationship and trust with residents in the effective delivery of high intensity functional exercise to older people living with dementia in care settings.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166686PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5132255PMC
June 2017

Walking Aids Moderate Exercise Effects on Gait Speed in People With Dementia: A Randomized Controlled Trial.

J Am Med Dir Assoc 2017 Mar 31;18(3):227-233. Epub 2016 Oct 31.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden; Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden.

Objectives: To investigate the effects of exercise on gait speed, when tested using walking aids and without, and whether effects differed according to amount of support in the test.

Design: A cluster-randomized controlled trial.

Setting: The Umeå Dementia and Exercise (UMDEX) study was set in 16 nursing homes in Umeå, Sweden.

Participants: One hundred forty-one women and 45 men (mean age 85 years) with dementia, of whom 145 (78%) habitually used walking aids.

Intervention: Participants were randomized to the high-intensity functional exercise program or a seated attention control activity.

Measurements: Blinded assessors measured 4-m usual gait speed with walking aids if any gait speed (GS), and without walking aids and with minimum amount of support, at baseline, 4 months (on intervention completion), and 7 months.

Results: Linear mixed models showed no between-group effect in either gait speed test at 4 or 7 months. In interaction analyses exercise effects differed significantly between participants who walked unsupported compared with when walking aids or minimum support was used. Positive between-group exercise effects on gait speed (m/s) were found in subgroups that walked unsupported at 4 and 7 months (GS: 0.07, P = .009 and 0.13, P < .001; and GS test without walking aids: 0.05, P = .011 and 0.07, P = .029, respectively).

Conclusions: In people with dementia living in nursing homes exercise had positive effects on gait when tested unsupported compared with when walking aids or minimum support was used. The study suggests that the use of walking aids in gait speed tests may conceal exercise effects.
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http://dx.doi.org/10.1016/j.jamda.2016.09.003DOI Listing
March 2017

Benefits of a Paleolithic diet with and without supervised exercise on fat mass, insulin sensitivity, and glycemic control: a randomized controlled trial in individuals with type 2 diabetes.

Diabetes Metab Res Rev 2017 01 30;33(1). Epub 2016 Jun 30.

Department of Public Health and Clinical Medicine, Medicine, Umeå University, Umeå, Sweden.

Background: Means to reduce future risk for cardiovascular disease in subjects with type 2 diabetes are urgently needed.

Methods: Thirty-two patients with type 2 diabetes (age 59 ± 8 years) followed a Paleolithic diet for 12 weeks. Participants were randomized to either standard care exercise recommendations (PD) or 1-h supervised exercise sessions (aerobic exercise and resistance training) three times per week (PD-EX).

Results: For the within group analyses, fat mass decreased by 5.7 kg (IQR: -6.6, -4.1; p < 0.001) in the PD group and by 6.7 kg (-8.2, -5.3; p < 0.001) in the PD-EX group. Insulin sensitivity (HOMA-IR) improved by 45% in the PD (p < 0.001) and PD-EX (p < 0.001) groups. HbA decreased by 0.9% (-1.2, -0.6; p < 0.001) in the PD group and 1.1% (-1.7, -0.7; p < 0.01) in the PD-EX group. Leptin decreased by 62% (p < 0.001) in the PD group and 42% (p < 0.001) in the PD-EX group. Maximum oxygen uptake increased by 0.2 L/min (0.0, 0.3) in the PD-EX group, and remained unchanged in the PD group (p < 0.01 for the difference between intervention groups). Male participants decreased lean mass by 2.6 kg (-3.6, -1.3) in the PD group and by 1.2 kg (-1.3, 1.0) in the PD-EX group (p < 0.05 for the difference between intervention groups).

Conclusions: A Paleolithic diet improves fat mass and metabolic balance including insulin sensitivity, glycemic control, and leptin in subjects with type 2 diabetes. Supervised exercise training may not enhance the effects on these outcomes, but preserves lean mass in men and increases cardiovascular fitness. Copyright © 2016 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/dmrr.2828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402870PMC
January 2017

Reliability and validity of the Swedish Fatigue Assessment Scale when self-administrered by persons with mild to moderate stroke.

Top Stroke Rehabil 2016 Apr 29;23(2):90-7. Epub 2016 Feb 29.

b Department of Community Medicine and Rehabilitation, Physiotherapy , Umeå University , S-901 87 Umeå , Sweden.

Objective: To examine internal consistency, test-retest reliability, floor/ceiling effects and construct validity of the Fatigue Assessment Scale (FAS), when self-administrated by persons with mild to moderate stroke.

Method: The FAS was translated into Swedish and tested for psychometric properties when self-administrated by persons with mild to moderate stroke. Participants, consequently selected from the stroke unit admission register received a letter with three questionnaires: the FAS, Short Form Health Survey (SF-36) subscale for vitality and Geriatric Depression Scale, GDS-15. Within two weeks, a second letter with FAS was sent for re-test.

Result: Seventy-tree persons with mild to moderate stroke participated in the study. Internal consistency was good (Cronbach's alpha 0.82). The test and retest reliability of individual items showed that five items out of 10 items were good (weighted kappa > 0.60), four were moderate (0.40-0.60), and one was fair (0.22). The relative reliability between total scores was good (ICC 3.1 = 0.73) and the absolute reliability was nine points, meaning that a change of at least nine points in total score implies a real change of fatigue level. Correlation analysis showed that the Swedish FAS correlated with the SF-36 subscale for vitality (rs = - 0.73) and GDS-15 (rs = 0.62), suggesting convergent construct validity. There were no floor or ceiling effects.

Conclusion: The Swedish translation of the FAS used as a self-administrated questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.
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http://dx.doi.org/10.1080/10749357.2015.1112057DOI Listing
April 2016

Effects of a High-Intensity Functional Exercise Program on Dependence in Activities of Daily Living and Balance in Older Adults with Dementia.

J Am Geriatr Soc 2016 Jan;64(1):55-64

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Objectives: To investigate the effects of a high-intensity functional exercise program on independence in activities of daily living (ADLs) and balance in older people with dementia and whether exercise effects differed between dementia types.

Design: Cluster-randomized controlled trial: Umeå Dementia and Exercise (UMDEX) study.

Setting: Residential care facilities, Umeå, Sweden.

Participants: Individuals aged 65 and older with a dementia diagnosis, a Mini-Mental State Examination score of 10 or greater, and dependence in ADLs (N=186).

Intervention: Ninety-three participants each were allocated to the high-intensity functional exercise program, comprising lower limb strength and balance exercises, and 93 to a seated control activity.

Measurements: Blinded assessors measured ADL independence using the Functional Independence Measure (FIM) and Barthel Index (BI) and balance using the Berg Balance Scale (BBS) at baseline and 4 (directly after intervention completion) and 7 months.

Results: Linear mixed models showed no between-group effect on ADL independence at 4 (FIM=1.3, 95% confidence interval (CI)=-1.6-4.3; BI=0.6, 95% CI=-0.2-1.4) or 7 (FIM=0.8, 95% CI=-2.2-3.8; BI=0.6, 95% CI=-0.3-1.4) months. A significant between-group effect on balance favoring exercise was observed at 4 months (BBS=4.2, 95% CI=1.8-6.6). In interaction analyses, exercise effects differed significantly between dementia types. Positive between-group exercise effects were found in participants with non-Alzheimer's dementia according to the FIM at 7 months and BI and BBS at 4 and 7 months.

Conclusion: In older people with mild to moderate dementia living in residential care facilities, a 4-month high-intensity functional exercise program appears to slow decline in ADL independence and improve balance, albeit only in participants with non-Alzheimer's dementia.
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http://dx.doi.org/10.1111/jgs.13880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4722852PMC
January 2016

Fall risk awareness and safety precautions taken by older community-dwelling women and men--a qualitative study using focus group discussions.

PLoS One 2015 17;10(3):e0119630. Epub 2015 Mar 17.

Department of Health Sciences, Division of Health and Rehabilitation, Luleå University of Technology, 97187 Luleå, Sweden.

Introduction: Daily life requires frequent estimations of the risk of falling and the ability to avoid a fall. The objective of this study was to explore older women's and men's understanding of fall risk and their experiences with safety precautions taken to prevent falls.

Methods: A qualitative study with focus group discussions was conducted. Eighteen community-dwelling people [10 women and 8 men] with and without a history of falls were purposively recruited. Participants were divided into two groups, and each group met four times. A participatory and appreciative action and reflection approach was used to guide the discussions. All discussions were audio recorded and transcribed verbatim. Data were analysed by qualitative content analysis, and categories were determined inductively.

Findings: Three categories describing the process of becoming aware of fall risks in everyday life were identified: 1] Facing various feelings, 2] Recognizing one's fall risk, and 3] Taking precautions. Each category comprised several subcategories. The comprehensive theme derived from the categories was "Safety precautions through fall risk awareness". Three strategies of ignoring [continuing a risky activity], gaining insight [realizing the danger in a certain situation], and anticipating [thinking ahead and acting in advance] were related to all choices of actions and could fluctuate in the same person in different contexts.

Conclusions: The fall risk awareness process might be initiated for various reasons and can involve different feelings and precautions as well as different strategies. This finding highlights that there are many possible channels to reach older people with information about fall risk and fall prevention, including the media and their peers. The findings offer a deeper understanding of older peoples' conceptualizations about fall risk awareness and make an important contribution to the development and implementation of fall prevention programmes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0119630PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363490PMC
February 2016

Community-dwelling older people with an injurious fall are likely to sustain new injurious falls within 5 years--a prospective long-term follow-up study.

BMC Geriatr 2014 Nov 18;14:120. Epub 2014 Nov 18.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umea University, 90187 Umea, Sweden.

Background: Fall-related injuries in older people are a leading cause of morbidity and mortality. Self-reported fall events in the last year is often used to estimate fall risk in older people. However, it remains to be investigated if the fall frequency and the consequences of the falls have an impact on the risk for subsequent injurious falls in the long term. The objective of this study was to investigate if a history of one single non-injurious fall, at least two non-injurious falls, or at least one injurious fall within 12 months increases the risk of sustaining future injurious falls.

Methods: Community-dwelling individuals 75-93 years of age (n = 230) were initially followed prospectively with monthly calendars reporting falls over a period of 12 months. The participants were classified into four groups based on the number and type of falls (0, 1, ≥2 non-injurious falls, and ≥1 injurious fall severe enough to cause a visit to a hospital emergency department). The participants were then followed for several years (mean time 5.0 years ±1.1) regarding injurious falls requiring a visit to the emergency department. The Andersen-Gill method of Cox regression for multiple events was used to estimate the risk of injurious falls.

Results: During the long-term follow-up period, thirty per cent of the participants suffered from at least one injurious fall. Those with a self-reported history of at least one injurious fall during the initial 12 months follow-up period showed a significantly higher risk for sustaining subsequent injurious falls in the long term (hazard ratio 2.78; 95% CI, 1.40-5.50) compared to those with no falls. No other group showed an increased risk.

Conclusions: In community-dwelling people over 75 years of age, a history of at least one self-reported injurious fall severe enough to cause a visit to the emergency department within a period of 12 months implies an increased risk of sustaining future injurious falls. Our results support the recommendations to offer a multifactorial fall-risk assessment coupled with adequate interventions to community-dwelling people over 75 years who present to the ED due to an injurious fall.
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http://dx.doi.org/10.1186/1471-2318-14-120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242483PMC
November 2014

End users transforming experiences into formal information and process models for personalised health interventions.

Stud Health Technol Inform 2014 ;205:378-82

Department of Community Medicine and Rehabilitation, UmeåUniversity, SWEDEN.

Five physiotherapists organised a user-centric design process of a knowledge-based support system for promoting exercise and preventing falls. The process integrated focus group studies with 17 older adults and prototyping. The transformation of informal medical and rehabilitation expertise and older adults' experiences into formal information and process models during the development was studied. As tool they used ACKTUS, a development platform for knowledge-based applications. The process became agile and incremental, partly due to the diversity of expectations and preferences among both older adults and physiotherapists, and the participatory approach to design and development. In addition, there was a need to develop the knowledge content alongside with the formal models and their presentations, which allowed the participants to test hands-on and evaluate the ideas, content and design. The resulting application is modular, extendable, flexible and adaptable to the individual end user. Moreover, the physiotherapists are able to modify the information and process models, and in this way further develop the application. The main constraint was found to be the lack of support for the initial phase of concept modelling, which lead to a redesigned user interface and functionality of ACKTUS.
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May 2015

Gender perspective on fear of falling using the classification of functioning as the model.

Disabil Rehabil 2015 30;37(3):214-22. Epub 2014 Apr 30.

Department of Community Medicine and Rehabilitation, Physiotherapy and.

Purpose: To investigate associations between fear of falling (FOF) and recurrent falls among women and men, and gender differences in FOF with respect to International Classification of Functioning (ICF).

Methods: Community-dwelling people (n = 230, 75-93 years, 72% women) were included and followed 1 year regarding falls. Data collection included self-reported demographics, questionnaires, and physical performance-based tests. FOF was assessed with the question "Are you afraid of falling?". RESULTS were discussed with a gender relational approach.

Results: At baseline 55% women (n = 92) and 22% men (n = 14) reported FOF. During the follow-up 21% women (n = 35) and 30% men (n = 19) experienced recurrent falls. There was an association between gender and FOF (p = 0.001), but not between FOF and recurrent falls (p = 0.79), or between gender and recurrent falls (p = 0.32). FOF was related to Personal factors and Activity and Participation. The relationship between FOF and Personal factors was in opposite directions for women and men.

Conclusions: Results did not support the prevailing paradigm that FOF increases rate of recurrent falls in community-dwelling people, and indicated that the answer to "Are you afraid of falling?" might be highly influenced by gendered patterns.
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http://dx.doi.org/10.3109/09638288.2014.914584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364267PMC
October 2015

Physical function and fear of falling 2 years after the health-promoting randomized controlled trial: elderly persons in the risk zone.

Gerontologist 2014 Jun 1;54(3):387-97. Epub 2013 Aug 1.

*Address correspondence to Lena Zidén, Institute of neuroscience and physiology/physiotherapy, University of Gothenburg, P.O. Box 455, SE-405 30 Göteborg, Sweden. E-mail:

Purpose Of The Study: To investigate the effects of 2 different health-promoting interventions on physical performance, fear of falling, and physical activity at 3-month, 1-year, and 2-year follow-ups of the study Elderly Persons in the Risk Zone.

Design And Methods: A randomized, three-armed, single-blind, and controlled study in which 459 independent and community-dwelling people aged 80 years or older were included. A single preventive home visit including health-promoting information and advice and 4 weekly senior group meetings focused on health strategies and peer learning, with a follow-up home visit, were compared with control. Functional balance, walking speed, fear of falling, falls efficacy, and frequency of physical activities were measured 3 months, 1 year, and 2 years after baseline.

Results: There were no or limited differences between the groups at the 3-month and 1-year follow-ups. At 2 years, the odds ratio for having a total score of 48 or more on the Berg Balance scale compared with control was 1.80 (confidence interval 1.11-2.90) for a preventive home visit and 1.96 (confidence interval 1.21-3.17) for the senior meetings. A significantly larger proportion of intervention participants than controls maintained walking speed and reported higher falls efficacy. At 1 and 2 years, a significantly higher proportion of intervention participants performed regular physical activities than control.

Implications: Both a preventive home visit and senior meetings reduced the deterioration in functional balance, walking speed, and falls efficacy after 2 years. The long-term effects of both interventions indicate a positive impact on postponement of physical frailty among independent older people.
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http://dx.doi.org/10.1093/geront/gnt078DOI Listing
June 2014

Usual gait speed independently predicts mortality in very old people: a population-based study.

J Am Med Dir Assoc 2013 Jul 23;14(7):529.e1-6. Epub 2013 May 23.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Objectives: In older people, usual gait speed has been shown to independently predict mortality; however, less is known about whether usual gait speed is as informative in very old populations, in which prevalence of multimorbidity and disability is high. The aim of this study was to investigate if usual gait speed can independently predict all-cause mortality in very old people, and whether the prediction is influenced by dementia disorder, dependency in activities of daily living (ADL), or use of walking aids in the gait speed test.

Design: Prospective cohort study.

Setting: Population-based study in northern Sweden and Finland (the Umeå 85+/GERDA Study).

Participants: A total of 772 participants with a mean age of 89.6 years, 70% women, 33% with dementia disorders, 54% with ADL dependency, and 39% living in residential care facilities.

Measurements: Usual gait speed assessed over 2.4 meters and mortality followed-up for 5 years.

Results: The mean ± SD gait speed was 0.52 ± 0.21 m/s for the 620 (80%) participants able to complete the gait speed test. Cox proportional hazard regression analyses adjusted for potential confounders were performed. Compared with the fastest gait speed group (≥ 0.64 m/s), the hazard ratio for mortality was for the following groups: unable = 2.27 (P < .001), ≤ 0.36 m/s = 1.97 (P = .001), 0.37 to 0.49 m/s = 1.99 (P < .001), 0.50 to 0.63 m/s = 1.11 (P = .604). No interaction effects were found between gait speed and age, sex, dementia disorder, dependency in ADLs, or use of walking aids.

Conclusion: Among people aged 85 or older, including people dependent in ADLs and with dementia disorders, usual gait speed was an independent predictor of 5-year all-cause mortality. Inability to complete the gait test or gait speeds slower than 0.5 m/s appears to be associated with higher mortality risk. Gait speed might be a useful clinical indicator of health status among very old people.
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http://dx.doi.org/10.1016/j.jamda.2013.04.006DOI Listing
July 2013

"The balancing act"--licensed practical nurse experiences of falls and fall prevention: a qualitative study.

BMC Geriatr 2012 Oct 15;12:62. Epub 2012 Oct 15.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, SE-90187, Umeå, Sweden.

Background: Falls are common in old age and may have serious consequences. There are many strategies to predict and prevent falls from occurring in long-term care and hospitals. The aim of this study was to describe licensed practical nurse experiences of predicting and preventing further falls when working with patients who had experienced a fall-related fracture. Licensed practical nurses are the main caretakers that work most closely with the patients.

Methods: A qualitative study of focus groups interviews and field observations was done. 15 licensed practical nurses from a rehabilitation ward and an acute ward in a hospital in northern Sweden were interviewed. Content was analyzed using qualitative content analysis.

Results: The result of the licensed practical nurse thoughts and experiences about risk of falling and fall prevention work is represented in one theme, "the balancing act". The theme includes three categories: "the right to decide", "the constant watch", and "the ongoing negotiation" as well as nine subcategories. The analysis showed similarities and differences between rehabilitation and acute wards. At both wards it was a core strategy in the licensed practical nurse work to always be ready and to pay attention to patients' appearance and behavior. At the rehabilitation ward, it was an explicit working task to judge the patients' risk of falling and to be active to prevent falls. At the acute ward, the words "risk of falling" were not used and fall prevention were not discussed; instead the licensed practical nurses used for example "dizzy and pale". The results also indicated differences in components that facilitate workplace learning and knowledge transfer.

Conclusions: Differences between the wards are most probably rooted in organizational differences. When it is expected by the leadership, licensed practical nurses can express patient risk of falling, share their observations with others, and take actions to prevent falls. The climate and the structure of the ward are essential if licensed practical nurses are to be encouraged to routinely consider risk of falling and implement risk reduction strategies.
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http://dx.doi.org/10.1186/1471-2318-12-62DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3536659PMC
October 2012

Determinants of self-rated health in old age: a population-based, cross-sectional study using the International Classification of Functioning.

BMC Public Health 2011 Aug 25;11:670. Epub 2011 Aug 25.

Department of Community Medicine and Rehabilitation, Division of Physiotherapy, Umeå University, Sweden.

Background: Self-rated health (SRH) is a widely used indicator of general health and multiple studies have supported the predictive validity of SRH in older populations concerning future health, functional decline, disability, and mortality. The aim of this study was to use the theoretical framework of the International Classification of Functioning, Disability and Health (ICF) to create a better understanding of factors associated with SRH among community-dwelling older people in urban and rural areas.

Methods: The study design was population-based and cross-sectional. Participants were 185 Icelanders, randomly selected from a national registry, community-dwelling, 65-88 years old, 63% urban residents, and 52% men. Participants were asked: "In general, would you say your health is excellent, very good, good, fair, or poor?" Associations with SRH were analyzed with ordinal logistic regression. Explanatory variables represented aspects of body functions, activities, participation, environmental factors and personal factors components of the ICF.

Results: Univariate analysis revealed that SRH was significantly associated with all analyzed ICF components through 16 out of 18 explanatory variables. Multivariate analysis, however, demonstrated that SRH had an independent association with five variables representing ICF body functions, activities, and personal factors components: The likelihood of a better SRH increased with advanced lower extremity capacity (adjusted odds ratio [adjOR] = 1.05, p < 0.001), upper extremity capacity (adjOR = 1.13, p = 0.040), household physical activity (adjOR = 1.01, p = 0.016), and older age (adjOR = 1.09, p = 0.006); but decreased with more depressive symptoms (adjOR = 0.79, p < 0.001).

Conclusions: The results highlight a collection of ICF body functions, activities and personal factors associated with higher SRH among community-dwelling older people. Some of these, such as physical capacity, depressive symptoms, and habitual physical activity are of particular interest due to their potential for change through public health interventions. The use of ICF conceptual framework and widely accepted standardized assessments should make these results comparable and relevant in an international context.
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http://dx.doi.org/10.1186/1471-2458-11-670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175467PMC
August 2011