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Randomised controlled trial
Two types of exercise programme for institutionalised older people may preserve the ability to perform some activities of daily living
  1. Terry Haines
  1. 1Physiotherapy Department, Monash University, Frankston, Victoria, Australia
  2. 2Allied Health Clinical Research Unit, Southern Health, Cheltenham, Victoria, Australia
  1. Correspondence to Terry Haines1 2
    Allied Health Clinical Research Unit, Southern Health, Kingston Centre, Kingston Road, Cheltenham, Victoria 3912, Australia; terrence.haines{at}med.monash.edu.au

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Functional decline among institutionalised older adults

Decline in ability to perform activities of daily living (ADLs) among institutionalised older adults is a widely observed phenomenon. Although many may feel that functional decline is inevitable among this group, it is possible that sedentary behaviour accelerates this process and that decline can therefore be addressed through physical activity programmes.1

Tai Chi or ‘cognition-action’ to mitigate functional decline

Dechamps and colleagues described a randomised controlled trial (n=160) comparing two activity programmes with a usual care control condition among older, mobile aged-care residents. Physical activity programmes have previously shown benefit for improving physical function among institutionalised older adults,1 and Tai Chi programmes have been adapted for older adults in a number of institutional settings.2 3 Inclusion criteria for this study were reasonably broad, although participants did have to understand basic motor commands, which may have eliminated many with impaired cognitive function. The primary outcome was independence in performing ADLs measured at 3, 6 and 12 months after study commencement. The intervention conditions were adapted Tai Chi (Yang style) and a novel exercise approached named ‘cognition-action’ by the investigators. The cognitive-action intervention is described only briefly, but reference is made to a pilot study (n=52) that contains some additional information.4 But even with this extra information, it is difficult to understand what patients participating in the cognition-action intervention actually did.

The inclusion of the cognitive-action intervention and the comparison of this with the Tai Chi and usual care groups was novel. The extended follow-up and the minimisation of attrition, particularly in this population (16% loss), were strengths of the study.

Potentially confusing finding

The authors reported a significant decline in ADL function in the control group but no significant decline in ADL function in the two intervention groups. However, they followed this statement with the finding that the change in ADL performance was not significantly different in the Tai Chi group compared with the control group or in the cognition-action group compared with the control group. Some differences were evident in secondary outcomes, but a large number of secondary outcomes were examined.

This study and its presentation create difficulties for novice readers. The presentation of the main findings may lead inexperienced readers to think that the interventions were successful. However, the direct comparison between the control and intervention groups indicated these were non-significant findings for the primary outcome measure (p=0.16). Thus readers must treat the author's conclusion that “targeted exercise intervention programs can slow the decline in HRQoL [health-related quality of life] in deconditioned, institutionalized elderly persons” with caution at this stage.

Lessons for conducting future research

Another concern is that the control group had poorer independence in ADL performance at baseline. This imbalance was not statistically significant, but rarely are clinical trials adequately powered to detect baseline differences of clinically important magnitude. There are two possible reasons for the imbalance: bias in the baseline assessment process and random variation among groups. The authors state that baseline assessors were physicians who were not informed of the participants' group allocation. However, it is not clear whether participants were aware of their allocation at this point. This knowledge might have influenced their performance, and they might have inadvertently informed the assessors. Thus, bias in the baseline assessment process, though unlikely, cannot be ruled out. Random variation is likely: baseline imbalances are not unusual in studies with simple randomisation strategies and moderate sample sizes, as in the present study. A dynamic randomisation approach might have mitigated this bias.

Should clinical practice be changed?

Although findings were encouraging, it is not yet clear that Tai Chi (Yang style) or cognition-action exercise programmes are better than usual care for improving functional independence in ADLs among institutionalised older adults. Given that additional resources are required on top of usual care to provide these programmes, the issue of economic efficiency (could these additional resources be better spent elsewhere?) also needs to be addressed. Further research is required to demonstrate the efficacy and economic efficiency of these programmes before implementation in clinical practice is considered.

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Footnotes

  • Competing interests None.

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