The Effects of Exercise on Falls in Older People
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Original Study
The Effects of Exercise on Falls in Older People With Dementia Living
in Nursing Homes: A Randomized Controlled Trial
Annika Toots PhD a, b, *, Robert Wiklund PT a, b
, Håkan Littbrand PhD a, b
,
Ellinor Nordin PhD a
, Peter Nordström PhD b , Lillemor Lundin-Olsson PhD a
,
Yngve Gustafson PhD b
, Erik Rosendahl PhD a, b
a Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
b Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
Keywords:
Falls
dementia
Alzheimer disease
exercise
residential facilities
fractures
a b s t r a c t
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) 0.5e1.7, P ¼ .838 and incidence rate ratio 0.9, 95% CI 0.5e1.6,
P ¼ .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 0.10e0.94, P ¼ .039).
Conclusions/Implications: In older people with dementia living in nursing homes, a high-intensity func-
tional 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.
Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
This work was supported by the Swedish Research Council (grant numbers
K2009-69P-21298-01-4, K2009-69X-21299-01-1, K2009-69P-21298-04-4, K2014-
99X-22610-01-6); Forte e Swedish Research Council for Health,Working Life and
Welfare (formerly FAS e Swedish Council for Working Life and Social Research); the
Vårdal Foundation; the Swedish Dementia Association; the Promobilia Foundation;
the Swedish Society of Medicine; the Swedish Alzheimer Foundation; the King
Gustav V and Queen Victoria’s Foundation of Freemasons; the European Union
Bothnia-Atlantica Program; the County Council of Västerbotten, the Umeå Univer-
sity Foundation for Medical Research; the Ragnhild and Einar Lundström’s Me-
morial Foundation; and the Erik and Anne-Marie Detlof’s Foundation.
Littbrand developed and has received royalties on the weighted belt used in the
exercise program.
The study sponsors’ had no role in the design, methods, subject recruitment,
data collection, analysis, or preparation of the article.
The authors declare no conflicts of interest.
* Address correspondence to Annika Toots, PhD, Department of Community
Medicine and Rehabilitation, Physiotherapy, Umeå University, 901 87 Umeå,
Sweden.
E-mail address: annika.toots@umu.se (A. Toots).
https://doi.org/10.1016/j.jamda.2018.10.009
1525-8610/Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
JAMDA
j o u r n a l h o m e p a g e : w w w . j a m d a . c o m
JAMDA 20 (2019) 835e842
The Effects of Exercise on Falls in Older People With Dementia Living
in Nursing Homes: A Randomized Controlled Trial
Annika Toots PhD a, b, *, Robert Wiklund PT a, b
, Håkan Littbrand PhD a, b
,
Ellinor Nordin PhD a
, Peter Nordström PhD b , Lillemor Lundin-Olsson PhD a
,
Yngve Gustafson PhD b
, Erik Rosendahl PhD a, b
a Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
b Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
Keywords:
Falls
dementia
Alzheimer disease
exercise
residential facilities
fractures
a b s t r a c t
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) 0.5e1.7, P ¼ .838 and incidence rate ratio 0.9, 95% CI 0.5e1.6,
P ¼ .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 0.10e0.94, P ¼ .039).
Conclusions/Implications: In older people with dementia living in nursing homes, a high-intensity func-
tional 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.
Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
This work was supported by the Swedish Research Council (grant numbers
K2009-69P-21298-01-4, K2009-69X-21299-01-1, K2009-69P-21298-04-4, K2014-
99X-22610-01-6); Forte e Swedish Research Council for Health,Working Life and
Welfare (formerly FAS e Swedish Council for Working Life and Social Research); the
Vårdal Foundation; the Swedish Dementia Association; the Promobilia Foundation;
the Swedish Society of Medicine; the Swedish Alzheimer Foundation; the King
Gustav V and Queen Victoria’s Foundation of Freemasons; the European Union
Bothnia-Atlantica Program; the County Council of Västerbotten, the Umeå Univer-
sity Foundation for Medical Research; the Ragnhild and Einar Lundström’s Me-
morial Foundation; and the Erik and Anne-Marie Detlof’s Foundation.
Littbrand developed and has received royalties on the weighted belt used in the
exercise program.
The study sponsors’ had no role in the design, methods, subject recruitment,
data collection, analysis, or preparation of the article.
The authors declare no conflicts of interest.
* Address correspondence to Annika Toots, PhD, Department of Community
Medicine and Rehabilitation, Physiotherapy, Umeå University, 901 87 Umeå,
Sweden.
E-mail address: annika.toots@umu.se (A. Toots).
https://doi.org/10.1016/j.jamda.2018.10.009
1525-8610/Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
JAMDA
j o u r n a l h o m e p a g e : w w w . j a m d a . c o m
JAMDA 20 (2019) 835e842
Older people with dementia have a higher risk of falls and fall-
related injuries compared with older people in general.1e3 The
increased risk can be attributed to symptoms such as cognitive and
physical impairment.1,3,4 Furthermore, people with non-Alzheimer’s
types of dementia (non- Alzheimer’s disease), for example, Lewy body
dementia and vascular dementia, seem to have a higher fall risk
compared with Alzheimer’s disease.1,5 Consequences of falls (eg, hip
fractures) can have a detrimental influence on functional ability and
survival in older persons,6 let alone persons with dementia, who,
following a hip fracture, appear to have even worse prognosis than
those without dementia.2,7,8 The number of older people with de-
mentia is projected to increase in the near future, and falls and fall-
related injuries not only contribute to the burden of illness, but will
also challenge public health resources worldwide.
In community-dwelling older populations, there is evidence that
physical exercise, as a single intervention, can prevent falls.9,10 Exer-
cise programs involving a high challenge to balance and performed at
least 3 times a week seem to have the greatest fall preventative ef-
fect.10 Also, in older people with cognitive impairment, promising
evidence of the effect of exercise on falls prevention is emerging.10,11
However, studies in people with dementia are comparatively few,
and most are set in the community.12e14 In nursing homes, where a
large proportion of the residents have dementia, there is limited ev-
idence of beneficial effects of exercise.10,15 Furthermore, improved
ability to ambulate independently may pose a higher risk of falls and
fall-related injuries through an increased exposure to high-risk
situations.15e17
Beneficial effects on balance of a high-intensity functional exercise
program in people with dementia living in nursing homes have been
found previously. The program appeared to particularly benefit par-
ticipants with non-Alzheimer’s disease compared with people with
Alzheimer’s disease,18 while no effects were observed on cognition.19
In addition, in older people with and without dementia living in
nursing homes, exercise programs have been shown to prevent falls
when balance was improved.20 The aim of this study was, therefore, to
investigate the effects of a high-intensity functional exercise program
on fall rate in people with dementia living in nursing homes, and if
effects were associated with sex, dementia type, or improvement in
balance. A further aim was to describe the occurrence of fall-related
injuries.
Methods
This study was part of the Umeå Dementia and Exercise Study
(UMDEX), a cluster-randomized controlled trial, set in 16 nursing
homes in Umeå, Sweden.18,19,21 The study protocol (ISRCTN31767087)
is published on the ISRCTN registry.
Participants
The UMDEX study included nursing home residents who had a
Mini-Mental State Examination (MMSE) score of at least 10,22 a de-
mentia diagnosis, 23 were aged 65 years or over, dependent on assis-
tance in at least 1 personal activities of daily living (ADL) according to
the Katz Index,24 had the ability to stand up from a chair with armrests
with assistance from no more than 1 person, physician’s approval, and
ability to hear and understand spoken Swedish sufficiently to partic-
ipate in assessments. All participants gave informed oral consent,
which was also confirmed by their next of kin. In the 864 nursing
home residents screened in total, age (P ¼ .189) and MMSE score
(P ¼ .713) did not differ between participants included and those who
declined participation (n ¼ 55; Figure 1). A larger proportion of men
than women declined participation (34% vs 18%; P ¼ .008).
Sample and Randomization
Sample size (n ¼ 186) for the UMDEX study was calculated based
on the main outcome, the Barthel ADL Index.18 In addition, a power
simulation was undertaken using data on participants with dementia
from a previous trial investigating exercise effects on falls,20 which
assumed a dispersion parameter of 2.0, a control group fall rate of 5.0
falls/person-year, and a 30% difference in fall rate between groups. A
sample size of 135 participants was required to have a 80% chance of
detecting such reduction in fall rate significant at the 5% level.
Participants were randomized after completion of enrolment
process and baseline assessment to ensure concealed allocation.
Clusters (n ¼ 36) of 3 to 8 participants each (who lived in the same
wing, unit, or floor) were formed to reduce contamination. The
randomization was stratified in all nursing homes except one that had
only a single cluster; the object being to have participants in both
exercise and attention control groups living in each nursing home,
which reduces the risk of site-specific factors influencing the outcome.
Two researchers not involved in the study performed randomiza-
tion by drawing lots using sealed opaque envelopes. The Regional
Ethics Review Board in Umeå approved the study (2011-205-31M).
Intervention
Physiotherapists (PT) led the exercise activities, and occupational
therapists (OT) or an OT assistant led the attention control activity.
Following exercise recommendations for general older populations,
the intervention consisted of 5 sessions per fortnight for the duration
of 4 months (40 sessions in total), with each session lasting approxi-
mately 45 minutes. Whenever possible, supervised individual sessions
were offered when participants were unable to attend a group session.
No activities were provided after the 4-month intervention. Partici-
pation in activities other than those provided by the study was not
restricted at any time.
The exercise intervention was based on the high-intensity func-
tional exercise program (HIFE), which includes a model for exercise
selection and a definition of exercise intensity (available online at
https://www.hifeprogram.se/en).18,25,26 In brief, the HIFE comprises
39 functional exercises for improved lower limb strength, balance,
and mobility to be performed with high intensity and in weight-
bearing positions similar to daily activities. High-intensity in
strength exercise is defined as 8e12 repetition maximum and in
balance exercise when postural stability is fully challenged.25,26 Ex-
ercises were tailored based on participants’ functional deficits. Par-
ticipants were supervised individually to promote the highest possible
exercise intensity, and adapted accordingly through progressive
adjustment of load and base of support, while also taking into account
participants’ symptoms and changes in health and functional status.
For safety, participants wore belts with handles so that PTs could
provide support if needed when postural stability was fully chal-
lenged, thereby preventing falls. Unnecessary support was avoided.
The attention control group participated in structured activities
that were developed by the OTs/OT assistant that led the activities. The
activities were structured around topics believed to be interesting for
older people, including local wild life, seasons, and holidays. While
seated in a group, participants conversed, sang, listened to music or
readings, and/or looked at pictures and objects.
At the end of each session, leaders completed a structured protocol
for each participant pertaining to adverse events, and in the exercise
group, intensity achieved in muscle strength and balance exercises,
which was estimated separately as high, moderate, or low according to
the predefined scale.25 All adverse events recorded during exercise
sessions were minor or temporary.27 In the exercise group, partici-
pants performed strength exercises with moderate intensity (40%)
and at high intensity (49%) of attended sessions, and balance exercises
A. Toots et al. / JAMDA 20 (2019) 835e842836
related injuries compared with older people in general.1e3 The
increased risk can be attributed to symptoms such as cognitive and
physical impairment.1,3,4 Furthermore, people with non-Alzheimer’s
types of dementia (non- Alzheimer’s disease), for example, Lewy body
dementia and vascular dementia, seem to have a higher fall risk
compared with Alzheimer’s disease.1,5 Consequences of falls (eg, hip
fractures) can have a detrimental influence on functional ability and
survival in older persons,6 let alone persons with dementia, who,
following a hip fracture, appear to have even worse prognosis than
those without dementia.2,7,8 The number of older people with de-
mentia is projected to increase in the near future, and falls and fall-
related injuries not only contribute to the burden of illness, but will
also challenge public health resources worldwide.
In community-dwelling older populations, there is evidence that
physical exercise, as a single intervention, can prevent falls.9,10 Exer-
cise programs involving a high challenge to balance and performed at
least 3 times a week seem to have the greatest fall preventative ef-
fect.10 Also, in older people with cognitive impairment, promising
evidence of the effect of exercise on falls prevention is emerging.10,11
However, studies in people with dementia are comparatively few,
and most are set in the community.12e14 In nursing homes, where a
large proportion of the residents have dementia, there is limited ev-
idence of beneficial effects of exercise.10,15 Furthermore, improved
ability to ambulate independently may pose a higher risk of falls and
fall-related injuries through an increased exposure to high-risk
situations.15e17
Beneficial effects on balance of a high-intensity functional exercise
program in people with dementia living in nursing homes have been
found previously. The program appeared to particularly benefit par-
ticipants with non-Alzheimer’s disease compared with people with
Alzheimer’s disease,18 while no effects were observed on cognition.19
In addition, in older people with and without dementia living in
nursing homes, exercise programs have been shown to prevent falls
when balance was improved.20 The aim of this study was, therefore, to
investigate the effects of a high-intensity functional exercise program
on fall rate in people with dementia living in nursing homes, and if
effects were associated with sex, dementia type, or improvement in
balance. A further aim was to describe the occurrence of fall-related
injuries.
Methods
This study was part of the Umeå Dementia and Exercise Study
(UMDEX), a cluster-randomized controlled trial, set in 16 nursing
homes in Umeå, Sweden.18,19,21 The study protocol (ISRCTN31767087)
is published on the ISRCTN registry.
Participants
The UMDEX study included nursing home residents who had a
Mini-Mental State Examination (MMSE) score of at least 10,22 a de-
mentia diagnosis, 23 were aged 65 years or over, dependent on assis-
tance in at least 1 personal activities of daily living (ADL) according to
the Katz Index,24 had the ability to stand up from a chair with armrests
with assistance from no more than 1 person, physician’s approval, and
ability to hear and understand spoken Swedish sufficiently to partic-
ipate in assessments. All participants gave informed oral consent,
which was also confirmed by their next of kin. In the 864 nursing
home residents screened in total, age (P ¼ .189) and MMSE score
(P ¼ .713) did not differ between participants included and those who
declined participation (n ¼ 55; Figure 1). A larger proportion of men
than women declined participation (34% vs 18%; P ¼ .008).
Sample and Randomization
Sample size (n ¼ 186) for the UMDEX study was calculated based
on the main outcome, the Barthel ADL Index.18 In addition, a power
simulation was undertaken using data on participants with dementia
from a previous trial investigating exercise effects on falls,20 which
assumed a dispersion parameter of 2.0, a control group fall rate of 5.0
falls/person-year, and a 30% difference in fall rate between groups. A
sample size of 135 participants was required to have a 80% chance of
detecting such reduction in fall rate significant at the 5% level.
Participants were randomized after completion of enrolment
process and baseline assessment to ensure concealed allocation.
Clusters (n ¼ 36) of 3 to 8 participants each (who lived in the same
wing, unit, or floor) were formed to reduce contamination. The
randomization was stratified in all nursing homes except one that had
only a single cluster; the object being to have participants in both
exercise and attention control groups living in each nursing home,
which reduces the risk of site-specific factors influencing the outcome.
Two researchers not involved in the study performed randomiza-
tion by drawing lots using sealed opaque envelopes. The Regional
Ethics Review Board in Umeå approved the study (2011-205-31M).
Intervention
Physiotherapists (PT) led the exercise activities, and occupational
therapists (OT) or an OT assistant led the attention control activity.
Following exercise recommendations for general older populations,
the intervention consisted of 5 sessions per fortnight for the duration
of 4 months (40 sessions in total), with each session lasting approxi-
mately 45 minutes. Whenever possible, supervised individual sessions
were offered when participants were unable to attend a group session.
No activities were provided after the 4-month intervention. Partici-
pation in activities other than those provided by the study was not
restricted at any time.
The exercise intervention was based on the high-intensity func-
tional exercise program (HIFE), which includes a model for exercise
selection and a definition of exercise intensity (available online at
https://www.hifeprogram.se/en).18,25,26 In brief, the HIFE comprises
39 functional exercises for improved lower limb strength, balance,
and mobility to be performed with high intensity and in weight-
bearing positions similar to daily activities. High-intensity in
strength exercise is defined as 8e12 repetition maximum and in
balance exercise when postural stability is fully challenged.25,26 Ex-
ercises were tailored based on participants’ functional deficits. Par-
ticipants were supervised individually to promote the highest possible
exercise intensity, and adapted accordingly through progressive
adjustment of load and base of support, while also taking into account
participants’ symptoms and changes in health and functional status.
For safety, participants wore belts with handles so that PTs could
provide support if needed when postural stability was fully chal-
lenged, thereby preventing falls. Unnecessary support was avoided.
The attention control group participated in structured activities
that were developed by the OTs/OT assistant that led the activities. The
activities were structured around topics believed to be interesting for
older people, including local wild life, seasons, and holidays. While
seated in a group, participants conversed, sang, listened to music or
readings, and/or looked at pictures and objects.
At the end of each session, leaders completed a structured protocol
for each participant pertaining to adverse events, and in the exercise
group, intensity achieved in muscle strength and balance exercises,
which was estimated separately as high, moderate, or low according to
the predefined scale.25 All adverse events recorded during exercise
sessions were minor or temporary.27 In the exercise group, partici-
pants performed strength exercises with moderate intensity (40%)
and at high intensity (49%) of attended sessions, and balance exercises
A. Toots et al. / JAMDA 20 (2019) 835e842836
with moderate intensity (26%) and high intensity (68%) of attended
sessions.27
Outcome Measures
Data on falls during the 4-month intervention and the 12-month
follow-up period (a total of 16 months) were collected by review of
fall incident reports in electronic medical records at nursing homes.
Nursing homes are required to routinely report time and place, as well
as consequences of falls. In addition, medical records at nursing homes
and the regional county council health care provider were reviewed for
references to falls during intervention and follow-up period. All re-
viewers were blinded to group allocation, and the study hypothesis was
not disclosed to participants, relatives, or staff. The primary, preplanned
outcome measure was fall rate at 6- and 12-month follow-up, measured
from the end of the intervention period when conceivably exercise ef-
fects on muscle strength, balance, and mobility were at optimum levels.
In addition, fall rate during intervention was analyzed for safety pur-
poses. A fall was defined as an event in which the participant unin-
tentionally came to rest on the floor or on the ground, regardless of
whether or not an injury was sustained or what caused the fall. This
definition is similar to one used in a previous study set in nursing
Screened for eligibility (n = 864) in nursing homes (n = 16)
Excluded (n = 678)
Inclusion criteria not met (n = 532)
<65 years (n = 16)
Independent in ADLs (n = 24)
Help to stand > 1 person (n = 243)
Severely impaired hearing (n = 3)
Not fluent in Swedish (n = 1)
MMSE < 10 (n = 156)
No demena diagnosis (n = 71)
Medical consent declined (n = 18)
Not present at care facility (n = 12)
Declined MMSE (n = 74)
Declined parcipaon (n = 55)
Deceased before allocaon (n = 5)
Individuals randomized (n = 186) in clusters
Exercise acvity 4 months (n = 93)
Clusters (n = 18)
Mean, SD/cluster (n = 5.2, 1.2)
Deceased (n = 6)
Control acvity 4 months (n = 93)
Clusters (n = 18)
Mean, SD/cluster (n = 5.2, 1.1)
Deceased (n = 4)
Follow-up interim 6 months (n = 87)
Deceased (n = 10)
Follow-up interim 6 months (n = 89)
Deceased (n = 12)
Move to Hospice (n = 1)
Follow-up total 12 months (n = 87)
Deceased (n = 25)
Follow-up total 12 months (n = 89)
Deceased (n = 27)
Move to Hospice (n = 1)
Included in primary analyses (n = 87) Included in primary analyses (n = 89)
Fig. 1. Flow of participants throughout the study.
A. Toots et al. / JAMDA 20 (2019) 835e842 837
sessions.27
Outcome Measures
Data on falls during the 4-month intervention and the 12-month
follow-up period (a total of 16 months) were collected by review of
fall incident reports in electronic medical records at nursing homes.
Nursing homes are required to routinely report time and place, as well
as consequences of falls. In addition, medical records at nursing homes
and the regional county council health care provider were reviewed for
references to falls during intervention and follow-up period. All re-
viewers were blinded to group allocation, and the study hypothesis was
not disclosed to participants, relatives, or staff. The primary, preplanned
outcome measure was fall rate at 6- and 12-month follow-up, measured
from the end of the intervention period when conceivably exercise ef-
fects on muscle strength, balance, and mobility were at optimum levels.
In addition, fall rate during intervention was analyzed for safety pur-
poses. A fall was defined as an event in which the participant unin-
tentionally came to rest on the floor or on the ground, regardless of
whether or not an injury was sustained or what caused the fall. This
definition is similar to one used in a previous study set in nursing
Screened for eligibility (n = 864) in nursing homes (n = 16)
Excluded (n = 678)
Inclusion criteria not met (n = 532)
<65 years (n = 16)
Independent in ADLs (n = 24)
Help to stand > 1 person (n = 243)
Severely impaired hearing (n = 3)
Not fluent in Swedish (n = 1)
MMSE < 10 (n = 156)
No demena diagnosis (n = 71)
Medical consent declined (n = 18)
Not present at care facility (n = 12)
Declined MMSE (n = 74)
Declined parcipaon (n = 55)
Deceased before allocaon (n = 5)
Individuals randomized (n = 186) in clusters
Exercise acvity 4 months (n = 93)
Clusters (n = 18)
Mean, SD/cluster (n = 5.2, 1.2)
Deceased (n = 6)
Control acvity 4 months (n = 93)
Clusters (n = 18)
Mean, SD/cluster (n = 5.2, 1.1)
Deceased (n = 4)
Follow-up interim 6 months (n = 87)
Deceased (n = 10)
Follow-up interim 6 months (n = 89)
Deceased (n = 12)
Move to Hospice (n = 1)
Follow-up total 12 months (n = 87)
Deceased (n = 25)
Follow-up total 12 months (n = 89)
Deceased (n = 27)
Move to Hospice (n = 1)
Included in primary analyses (n = 87) Included in primary analyses (n = 89)
Fig. 1. Flow of participants throughout the study.
A. Toots et al. / JAMDA 20 (2019) 835e842 837
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