Despite countless programs to reduce falls in older people over the last 25 years, the rates have not fallen. Research groups all over the world are trying to combat this problem, including those from Neuroscience Australia (NeuRA) who recently showed Technology Review the latest in their high-tech quests for a solution.
Move forwards and backwards, feet hip width, the instructor says to introduce the activity:
“Before starting, make sure you have a chair next to you. Begin with your feet hip-width apart. Keep one finger on the chair so you can hold on if needed…”
Her voice is youthful, encouraging, soothing and clear. Verbal instructions are accompanied by a physical demonstration. She says:
“… slowly rise up onto your toes and lower yourself back down to the ground and then lift your toes up to the ceiling so your weight is on your heels. Try to control the movement as you slowly rock between rising up onto your toes and lifting onto your heels.”
You are now ready to complete a simple balance exercises. Your instructor is the voice and animation in an instructional video for an iPad app being tested in a 500-person clinical trial primary aimed at reducing falls in older people.
The app, Standing Tall, has been developed by a falls prevention team at NeuRA led by Dr Kim Delbaere, a research fellow and group leader. It aims to improve an older person’s balance and engage them to do two hours of balances exercises a week, which is what the literature recommends, she says.
“When you are over 65 or 70 you should do [balance exercises] every day for the rest of your life and they are really boring,” Dr Delbaere tells Australian Ageing Agenda.
To combat the monotony and boredom, Delbaere and her team have added over 2,000 exercises to the app and designed it to be completely responsive to the individual’s ability, and schedule.
It is a year-and-a-half in the making and backed by literature, systematic reviews and feedback from focus groups of older people.
The resulting program is presented in a sequence that progresses with user ability with checkpoints along the way, Delbaere explains. It comes with a stepping mat, a foam cushion to give an unstable surface, and a box.
People can select session length to suit their schedule such as 10 minutes if they are short of time or 40 minutes to get it out of the way, she says.
“They can choose and we can generate the exercises at their level for the amount of time that they elected.”
Users can schedule reminders, see how many minutes they have done and whether they are on track to meet the two-hour weekly target. If they haven’t reached their goal, it is red and green if they have.
There are gaming-style features – each exercise has a score which is graded by its difficulty level – that allow users to see session scores and track progress over time.
Accompanying each exercise is an optional instructional video. There are also visual and audio cues during each activity.
“The exercise is shown on the screen. The timing changes as they progress. It shows their foot position and how many left they have to do. They can watch the timing on the screen or they can listen to the timing, whichever way they prefer,” Delbaere says.
After each activity the user enters feedback on how they felt, such as stable or unstable or whether it was too difficult.
“If they say this was easy for me, they will progress and will move forward to the next checkpoint and a whole new range of exercises,” says Delbaere.
The study involves participants aged 70 and over, 250 each in the intervention and control groups. For two years, all participants receive an iPad and the information program, which includes a weekly factsheet, and take part in weekly feedback. Only the intervention group gets the app and follows the exercise program.
Delbaere says they will take a baseline measurement of each participant at the beginning, return after a month to ensure they haven’t changed the set up, then follow up every six months.
“We are very confident that it will improve balance but we will have to wait and see if we can reduce falls. It’s always difficult. It is the most difficult outcome to have. One of the other outcomes is to see whether we can get people more active.”
Cognition is also being tested because the interaction with the program could improve executive function as well, says Delbaere.
Weekly online questionnaires will further measure quality of life, fear of falling and physical activity levels. They are also using other technology to monitor gait over a week [see panel].
Everything is being measured and automatically transmitted through the iPad for two years, says Delbaere, who adds the length of follow up is longer than many studies.
“People will get a pop up every week asking ‘Did you fall this week?’ ‘No I didn’t fall’ and that’s it. They don’t have to fill in the questionnaire and send it back. We hope it will make it a lot easier.”
If successful for balance aims, the app could in the app marketplace quite quickly because it is already fully developed, Delbaere says. The first participant began in early February and researchers expect to begin analysing the first 200 participants for balance outcomes in early 2016.
The team is recruiting participants throughout 2015. They are ideally looking for people who live within 20km of NeuRA, which is in the Sydney suburb of Randwick.
Contact the research team on research team on 02 9399 1888 or firstname.lastname@example.org.
* * * *
A sensor device worn around the neck on a lanyard or the waist on a belt is measuring everything NeuRA falls research participants do for a week as part of a remote monitoring program to capture an unbiased picture of a person’s gait.
NeuRA researcher officer Dr Matthew Brodie, says gait has previously only been monitored in a controlled test setting where people tend to walk like robots.
“What they do in the lab is their best performance, it doesn’t reflect what they do at home. If you measure them for about a week you can tell a lot of interesting things,” Dr Brodie tells Australian Ageing Agenda.
Dr Brodie is responsible for the ongoing development of an algorithm that transforms the collected data into useful information.
“At the moment we have broken what they do into three components. You have the quantity of their walking, which is basically what a pedometer does. But also we can do the quality of their walking and the intensity of their walking,” he says.
With walking quantity, Brodie says they are further looking at the distribution of the walks, which can’t be done with a pedometer, and they are finding that healthy people complete more long walks.
“Healthier people will complete some really long walks for several minutes. Less healthy people might have the same amount of steps but they won’t have those really long walks.”
The propensity to do longer walks is a better indication than just the number of steps completed, he says.
“You need to monitor them for about a week to pick that up because there is no guarantee they are going to do the same amount of walking each day.”
The algorithm can pick up subtle changes in a person’s gait in their daily activity that can’t be seen by the naked eye, says Brodie.
“There’s a lot of information buried in there from a weeks’ worth of walking. Some things affect everything. For example, we found a fear of falling affected just about every aspect of their walking.”
The idea is that this technique will be able to predict what’s going to happen in the future to intervene before a person has a fall or the quality of their life spirals out of control, he says.
Participants in all of NeuRA’s falls studies will wear a device for a week at the beginning of their trial. They will be followed up intervals, such as six and 12 month, to see how those activities change.
The method will be used on participants in both the control and intervention groups. “In the intervention group, we hope to see some change in a good way,” Dr Brodie says.
* * * *
A balanced approach
Space Invaders, Pac-Mac, Tetris and Pong are making a comeback but this time as a key feature of a newly-funded falls-prevention project at NeuRA.
The randomised-control study of 750 older people, which builds on two previous sample-size projects using a dance mat, is investigating whether step training can improve balance, mobility and cognition, and prevent falls.
NeuRA laboratory director and senior principal research fellow Professor Stephen Lord says findings from the previous two trials of older people are encouraging. This four-year study combines the two but with a big enough sample to definitively tell if the approach will prevents falls, he says.
“People who do the step mat exercises improve in their balance and their stepping ability. That improves what you think it might; the ability to take a quick and accurate step,” Professor Lord told Australian Ageing Agenda.
“That’s really important because that’s what we need to do to avoid a lot of falls. To get the recovery in place quickly but also to the right spot with the right force.”
The second study, which built video games into the step training program including the tile-matching puzzle game Tetris, additionally showed improved cognitive ability, he says.
This time they are developing a range of games and using other gaming principles to keep people engaged, interested and active for a full year, Lord says.
In addition to balance games, the team is developing some of the old arcade-style games including Pong, Pac-Man and Space Invaders, says Professor Lord.
“You can imagine say with Space Invaders you will have to quickly step sideways to get behind the blocks and step forward to shoot. There will be no jumping over but maybe a step back for when the aliens come so you will have to scan the screen and think, but all the time you are on your feet doing exercises.”
Participants will be assigned a core set of training games plus offered electives to choose, with an aim to progress in the level of difficulty of the games with new games unlocked as they improve.
An exciting feature of this research, says Lord, is in addition to the intervention and control groups of 250 people each, there will be a third group doing the exercises seated to test the cognition component only.
Participants in that group will make the same moves as the standing group but using their hands on a mini-dance mat placed on a desk, he says.
“There is some evidence that maybe even just the thinking will be good enough to improve and to prevent falls,” Professor Lord says.
Game development is almost complete and recruitment is due to begin mid-2015.
* * * *
This article currently appears in the March-April issue of AAA.