Scoping question: Does physical exercise training (progressive resistance training or multimodal exercise) produce any benefit or harm for older people with limitations in activities of daily living (ADLs)? The full ICOPE guidelines and complete set of evidence profiles are available at: who.int/publications/i/item/9789241550109# ICOPE guidelines -World Health Organization
A recent meta-analysis of 54 studies reported that the prevalence of limitations in activities of daily living (ADL) was 39% among older people over 65 years of age, three times the proportion in working age groups (1). With increasing age, the ability of older people to perform basic activities declines. The rate of decline is not homogeneous, however, and is largely determined by the environments people inhabit. Population studies have shown that up to 20% of older people improve their ability with exercise interventions (2), and many frequently transit between high and low capacity within the same age group (3). This dynamic nature provides room for restoration and maintenance of optimal physical capacity even in the oldest age group.
A growing body of evidence suggests strong associations between a reduced ability to perform basic activities and adverse outcomes, such as premature mortality (4), institutionalization (5,6), risk of falls (7), depression (8), cognitive impairment (9) and decreased quality of life (10). Intervention trials of multimodal physical exercise training targeting modifiable risk factors such as strength and balance have shown significant benefits for older people with reduced physical capacity, even in the very old and severely impaired (11). Simple physical exercise, such as walking, has shown significant reductions in the levels of need for assistance in daily activities (12). There is also empirical support from earlier reviews for the benefit of exercise on behaviour, cognition, communication and functioning in older people with cognitive impairments.
In this context, understanding the effect of physical exercise on older people with limitations in physical and cognitive function is extremely important. To assess its benefits, we reviewed the evidence of the effects of physical exercise on muscle strength, balance, gait speed, chair stand, timed up and go, ADL and physical functioning measured by the Short Physical Performance Battery (13). Although evidence from developed countries has shown potential benefit of physical-activity programmes for older people, it is still unclear whether such evidence and recommendations could be relevant for older people in lowresource health care settings, where the majority of older people in the world reside.

# ICOPE guidelines -World Health Organization

# Search strategy
The following electronic databases were used to identify studies for this review: Ovid MEDLINE, 1966to April 2011EMBASE, 1960

# List of systematic reviews identified by the search process
Included in GRADE 1

# Narrative description of the studies that went into analysis
Systematic reviews on physical exercise for older people without dementia Cadore et al. conducted a systematic review of the effects of different exercise interventions on risk of falls, gait ability and balance in physically frail older adults. Studies published from 1990 to 2012 were searched in the Scientific Electronic Library Online (SciELO), Science Citation Index, MEDLINE, Scopus, SPORTDiscus, and ScienceDirect databases. Twenty studies were included in their review. Seven out of the 20 studies (1420 participants), which recruited frail older people or those with a history of falling or a risk of falls, were added to the scope of this review conducted for the guidelines process. The average ages ranged from 72 to 83 years. The duration of exercise ranged from 10 weeks to 1 year. Six trials applied multimodal exercise and one applied progressive resistance exercise. The lead authors of these seven studies were from Australia, Brazil, Germany, Japan and USA.
Chou et al. conducted a meta-analysis to evaluate the effect of exercise on physical function, activities of daily living, and quality of life in the frail older adults. Studies published between 2001 and 2010 were searched in PubMed, MEDLINE, EMBASE, Chinese Electronic Periodical Service, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). Eight trials (1,068 participants) were included in their review. After removing ineligible trials and any that had already been included in this review by WHO, one trial (311 participants with a mean age of 81 years) was added to the scope review. The trial intervention was t'ai chi for 48 weeks. Daniels et al. conducted a systematic review of intervention studies to prevent disability in community-dwelling physically frail older adults. The PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL databases were searched in May 2007. Ten studies were included in their review. Out of the 10 studies, seven were excluded by this review by WHO (two had been included in the scope review, two included an active control, two combined nutrition programmes, and one included a homesafety programme). The three selected studies (277 participants) for this scope review were randomized controlled trials published by authors from Denmark, Netherlands, and USA. Participants either had mobility limitations or were considered frail. The mean age ranged from 77 to 81 years. The sample size ranged from 46 to 155 participants. The exercise duration ranged from 12 weeks to 10 months. All three trials used multimodal exercise. After removing ineligible trials and any that had already been included in this scope review, four trials (160 participants with mean ages ranging from 76.9 to 81.9 years) published from France, Israel, Korea and UK were added to this review. All trials used multimodal exercise with a duration ranging from 2 weeks to 12 months.

# LOW CRITICAL
ADLs: activities of daily living; MD: mean difference; RR: relative risk a. Risk of bias: Downgraded once as allocation concealment was unclear in four trials and information on incomplete data was not adequately described in three trials. b. Risk of bias: Downgraded once as allocation concealment was unclear in three trials and procedure for masking outcome assessor was unclear in two trials. c. Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau2 = 0.01; Chi2 = 12.80, df = 6 (P = 0.03; I2 = 61%). d. Risk of bias: Downgraded once as outcome assessor was not masked in one trial. e. Imprecision: Downgraded twice as sample size was very small. f. Risk of bias: Downgraded once as allocation concealment was unclear in four trials and procedure for masking outcome was unclear in three trials. g. Risk of bias: Downgraded once as information on incomplete data was unclear in two trials. h. Risk of bias: Downgraded once as allocation concealment was unclear in five trials and outcome assessors were not masked in three trials. i. Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau2 = 0.14; Chi2 = 33.17, df = 7
; I2 = 69%).

# ICOPE guidelines -World Health Organization

# MODERATE CRITICAL
ADLs: activities of daily living; SMD: standardized mean difference a. Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis for the estimate (heterogeneity: Tau2 = 0.17; Chi2 = 2.18, df = 15 P = 0.0007; I2 = 84%). This is mainly due to very large treatment effect from one of the included trials. b. Inconsistency: Downgraded once as considerable heterogeneity was observed in the meta-analysis for the estimate (heterogeneity: Tau2 = 0.94; Chi2 = 3.92, df = 4 ; I2 = 75%). No further subgroup analysis was conducted to explore heterogeneity, and we were not able to explain the heterogeneity. c. Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis for the estimate (heterogeneity: Tau 2 = 0.04; Chi 2 = 33.50, df = 8 ; I2 = 52%). No further subgroup analysis was conducted to explore heterogeneity, and we were not able to explain the heterogeneity. d. Risk of bias: Downgraded once as allocation concealment and procedure for masking outcome assessors were unclear in two trials. e. Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis for the estimate (heterogeneity: Tau 2 = 0.15;
Chi 2 = 3.31, df = 4 ; I2 = 67%). No further subgroup analysis was conducted to explore heterogeneity, and we were not able to explain the heterogeneity. f. Imprecision: Downgraded once as wide confidence intervals were observed for the estimate. g. Risk of bias: Downgraded once as outcome assessor was not masked in half of the included trials. h. Inconsistency: Downgraded once as moderate heterogeneity was observed for the estimate (heterogeneity: Tau2 = 0.21; Chi2 = 12.11, df = 7
; I2 = 61%). No further subgroup analysis was conducted to explore heterogeneity, and we were not able to explain the heterogeneity. i. Inconsistency: Downgraded once as moderate heterogeneity was observed for the estimate (heterogeneity: Chi 2 = 25.55, df = 6 ; I2 = 49%). No further subgroup analysis was conducted to explore heterogeneity, and we were not able to explain the heterogeneity. j. Inconsistency: Downgraded once as considerable heterogeneity was observed for the estimate (heterogeneity: Tau2 = 0.85; Chi2 = 2.92, df = 9 ; I2 = 71%). No further subgroup analysis was conducted to explore heterogeneity, and we were not able to explain the heterogeneity.

# Benefits and harms Explanation
Do the desirable effects outweigh the undesirable effects?
Yes No Uncertain  Progressive resistance exercise in older people with limitations in physical function:
- There is low-quality evidence for the effect of progressive resistance exercise on increasing muscle strength. - There is very low-quality evidence for the effect of progressive resistance exercise on improving chair stand performance.
Multimodal exercise in older people with limitations in physical function:
- There is moderate-quality evidence for the effect of multimodal exercise on increasing muscle strength. - There is moderate-quality evidence for the effect of multimodal exercise on improving balance. - There is moderate-quality evidence for the effect of multimodal exercise on improving chair stand performance. - There is low-quality evidence for the effect of multimodal exercise on improving overall physical function. - There is moderate-quality evidence for the effect of multimodal exercise on improving activities of daily living.
T'ai chi in older people with limitations in physical function:
- There is low-quality evidence for the effect of t'ai chi on improving balance.
Adverse events were reviewed if reported in the text. Musculoskeletal adverse events, such as muscle soreness and joint pain, were common among studies and might be related to exercise. Few studies reported severe adverse events such as fracture, hospitalization or death. The relationship between these severe events and exercise was not clear, however. The GDG believes that this recommendation would be acceptable to older people and stakeholders. Multimodal exercise is consistent with the value of the promotion of their capacity and skills. Family members might also value the intervention when improved mobility is achieved. However, context-related issues might hamper the value of intervention in some settings, particularly in low-and middle-income countries. Therefore, adapting the intervention to the local context might be required in low-and middle-income countries. Further consultation with external advisory groups, and adaptation guides may be required to scale up interventions in culturally diverse settings.

# Feasibility/resource use Explanation
How large are the resource requirements?
Major Minor Uncertain  Training, particularly involving the equipment for administering exercise interventions, is resourceintensive. However, the health benefit gained from the recommendation is likely to outweigh the resources required for implementation. Some factors can mitigate the cost, such as task-shifting, engaging with family members, and the training-of-trainers model.

# Is the option feasible to implement?
No Uncertain  In this review, some trials involved non-specialist health-care professionals in the delivery of the exercise intervention. In low-and middle-income countries, non-specialist health-care workers/community health volunteers at primary care level/community level have been involved in (continued next page) delivering this public health intervention effectively. Such professionals can be trained to provide care for older people. However, whether existing staff can be involved or not requires further discussion with policy-makers and key stakeholders. A separate cadre of non-specialist health workers for geriatric care might be necessary.

# Equity Explanation
Would the option improve equity in health?
Yes No Uncertain 
The GDG strongly believes that this recommendation will increase equity in health. Adherence to physical exercises without assistance is more prominent in higher-income and better-educated older populations.
Evidence profile: mobility loss ICOPE guidelines -World Health Organization
- Compliance rates were found to decline in multimodal training programmes that used a transition approachstarting, that is, with group exercise classes with a high level of supervision, and then reducing the frequency of these classes as home-based exercises were added in. - Commitments to, and compliance with, training programmes are crucial to achieving optimal benefits. Supervision by trained professionals may therefore be needed for high-intensity exercise and homebased training programmes. - Exercise programmes designed for older adults with limitations in cognitive function should be tailored to meet individual needs, and should be delivered with more flexibility in a less structured manner than programmes for older people without impaired cognitive function.

# Evidence-to-recommendations table Problem Explanation
Is the problem a priority?
No Uncertain  Population studies have found that nearly 40% of older people experience limitations in performing daily activities. Evidence also suggests a strong relationship between declines in functional ability and adverse outcomes, such as mortality, institutionalization, falls, morbidities, depression, cognitive impairment and decreased quality of life. Addressing functional indicators (muscle strength and balance) is therefore crucial for attenuating adverse outcomes for older people.

# Strength of the recommendation: Strong

# Quality of evidence: Moderate
- The effects and quality of evidence for stand-alone progressive resistance training and t'ai chi were not considered sufficient for incorporation into the recommendation. - The duration of multimodal exercise intervention ranged from 2.7 to 12 months.
- The frequency of training was most commonly 3 days per week.
- There was a marked heterogeneity in the exercise components included in multimodal exercise trials. It may be important to distinguish the effect size for different combinations of exercises for a more accurate estimate of the effects. - The majority of the trials included in the systematic reviews were conducted in high-income countries. There may be limitations in generalizing this evidence to low-resource health-care settings.
- The average age of the older people recruited in the trials evaluated may be over that of a target population in low-and middle-income countries. This may influence the generalizability of these findings to these populations.
(continued next page) - population (n = 120)
- intervention (n = 78)
- comparison (n = 5)
- outcome (n = 90)
- duplication (n = 9)
- non-English publication (n = 1)
- conference proceeding (n = 1)
- commentary (n = 1)
Records after duplicates removed (n = 325)
Records screened (n = 325)
Full-text articles assessed for eligibility (n = 20)
Full-text articles excluded, with reasons (n = 9)
- trials in these reviews were cited in included reviews