Considerations for maintaining functional mobility in older populations
Authors: Michael D Keall
Journal: The Lancet Public Health (2022)

The Retirement in Action (REACT) trial of Afroditi Stathi and colleagues1Stathi A Greaves CJ Thompson JL et al.Effect of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: the REACT (Retirement in Action) randomised controlled trial.Lancet Public Health. 2022; (published online March 21.)https://doi.org/10.1016/S2468-2667(22)00004-4/Summary Full Text Full Text PDF Scopus (2) Google Scholar has important public health implications. The population of older adults is expanding, with an accompanying growing health burden due to age-related reduced independence and consequent poorer quality of life. Interventions that promote functional mobility in older people, such as those described in their Article, are therefore very important. In this Comment, I discuss the importance of the outcomes tested by the REACT trial and describe some extrinsic factors that are outside the scope of exercise-based interventions but need to be part of an effective public health response to this issue. Falls and fall-related injuries were secondary outcomes in the REACT trial and were not found to be significantly affected by the intervention.1Stathi A Greaves CJ Thompson JL et al.Effect of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: the REACT (Retirement in Action) randomised controlled trial.Lancet Public Health. 2022; (published online March 21.)https://doi.org/10.1016/S2468-2667(22)00004-4/Summary Full Text Full Text PDF Scopus (2) Google Scholar Injuries from falls are very common in community-dwelling people aged 65 years or older, resulting in reduced quality of life, mobility, and independence.2Hartholt KA van Beeck EF Polinder S et al.Societal consequences of falls in the older population: injuries, healthcare costs, and long-term reduced quality of life.J Trauma. 2011; 71: 748-753Crossref PubMed Scopus (273) Google Scholar Exercise interventions for community-dwelling older people have been shown to reduce the incidence of falls.3Karlsson MK Magnusson H von Schewelov T Rosengren BE Prevention of falls in the elderly—a review.Osteoporos Int. 2013; 24: 747-762Crossref PubMed Scopus (155) Google Scholar Given the projected increase in the burden of falls for this age group, it is important to address both intrinsic risk factors (via exercise programmes and drug withdrawal) and extrinsic factors, such as the risks posed by the home environment.3Karlsson MK Magnusson H von Schewelov T Rosengren BE Prevention of falls in the elderly—a review.Osteoporos Int. 2013; 24: 747-762Crossref PubMed Scopus (155) Google Scholar Assessment and modification of the home environment has been shown to be particularly effective in preventing fall-related injuries in the home for all age groups,4Keall MD Pierse N Howden-Chapman P et al.Home modifications to reduce injuries from falls in the home injury prevention intervention (HIPI) study: a cluster-randomised controlled trial.Lancet. 2015; 385: 231-238Summary Full Text Full Text PDF PubMed Scopus (124) Google Scholar which is a rationale for measures that promote safer housing more generally. We recently showed that New Zealand's Indigenous Māori population, who suffer a range of health inequities, might benefit particularly from home modification to prevent falls.5Keall MD Tupara H Pierse N et al.Home modifications to prevent home fall injuries in houses with Māori occupants (MHIPI): a randomised controlled trial.Lancet Public Health. 2021; 6: e631-e640Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar This finding highlights the potential for safer environments to address aspects of health inequities. The REACT trial reported increases in the amount of daily physical activity of moderate-to-vigorous intensity in the intervention group compared to the control group. This was an important finding as there are generally low rates of physical activity among older people, despite the clear health benefits.6Vogel T Brechat PH Leprêtre PM Kaltenbach G Berthel M Lonsdorfer J Health benefits of physical activity in older patients: a review.Int J Clin Pract. 2009; 63: 303-320Crossref PubMed Scopus (306) Google Scholar Walking is by far the most common form of physical activity for older people.7Dafna M Carmen C Kamalesh V Adrian B How diverse was the leisure time physical activity of older Australians over the past decade?.J Sci Med Sport. 2012; 15: 213-219Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar Extrinsic factors that promote walking include the quality of the built environment in terms of walkability, residential density, and street connectivity; accessibility of destinations and services; street environments that are attractive to pedestrians; and safety.8Barnett DW Barnett A Nathan A Van Cauwenberg J Cerin E Built environmental correlates of older adults' total physical activity and walking: a systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2017; 14: 103Crossref PubMed Scopus (335) Google Scholar In addition, the quality and availability of public transport is also important.9Voss C Sims-Gould J Ashe MC McKay HA Pugh C Winters M Public transit use and physical activity in community-dwelling older adults: combining GPS and accelerometry to assess transportation-related physical activity.J Transp Health. 2016; 3: 191-199Crossref Scopus (27) Google Scholar In terms of policies to enhance older people's health and wellbeing and to reduce the burden on the health sector, it is therefore important to implement programmes such as those tested in the REACT trial, as well as promoting built environments (including homes and urban settings) that are safe and promote walking. Such environments are beneficial to all age groups, not just older people. The REACT trial was not powered to compare outcomes for different subgroups, which could have informed probable effects of the intervention on health inequities. To reduce health inequities in general, there needs to be planned delivery of programmes that specifically address the differential levels of access and uptake.10Glasgow RE Askew S Purcell P et al.Use of RE-AIM to address health inequities: application in a low-income community health center-based weight loss and hypertension self-management program.Transl Behav Med. 2013; 3: 200-210Crossref PubMed Scopus (54) Google Scholar I declare no competing interests. Effect of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: the REACT (Retirement in Action) randomised controlled trialFor older adults at risk of mobility limitations, the REACT intervention showed that a 12-month physical activity and behavioural maintenance programme could help prevent decline in physical function over a 24-month period. Full-Text PDF Open Access