A group-based exercise and behavioural maintenance intervention for adults over 65 years with mobility limitations: the REACT RCT
Background Mobility limitation in older age reduces quality of life, generates substantial health- and social-care costs, and increases mortality. Objective The REtirement in ACTion (REACT) trial aimed to establish whether or not a community-based active ageing intervention could prevent decline in physical functioning in older adults already at increased risk of mobility limitation. Design A multicentre, pragmatic, two-arm, parallel-group randomised controlled trial with parallel process and health economic evaluations. Setting Urban and semi-rural locations across three sites in England. Participants Physically frail or pre-frail older adults (aged ≥65 years; Short Physical Performance Battery score of 4–9). Recruitment was primarily via 35 primary care practices. Interventions Participants were randomly assigned to receive brief advice (three healthy ageing education sessions) or a 12-month, group-based, multimodal exercise and behavioural maintenance programme delivered in fitness and community centres. Randomisation was stratified by site and used a minimisation algorithm to balance age, sex and Short Physical Performance Battery score. Data collection and analyses were blinded. Main outcome measures The primary outcome was change in lower limb physical function (Short Physical Performance Battery score) at 24 months, analysed using an intention-to-treat analysis. The economic evaluation adopted the NHS and Personal Social Services perspective. Results Between June 2016 and October 2017, 777 participants (mean age 77.6 years, standard deviation 6.8 years; 66% female; mean Short Physical Performance Battery score 7.37, standard deviation 1.56) were randomised to the intervention arm (n=410) or the control arm (n=367). Data collection was completed in October 2019. Primary outcome data at 24 months were provided by 628 (80.8%) participants. At the 24-month follow-up, the Short Physical Performance Battery score was significantly greater in the intervention arm (mean 8.08, standard deviation 2.87) than in the control arm (mean 7.59, standard deviation 2.61), with an adjusted mean difference of 0.49 (95% confidence interval 0.06 to 0.92). The difference in lower limb function between intervention and control participants was clinically meaningful at both 12 and 24 months. Self-reported physical activity significantly increased in the intervention arm compared with the control arm, but this change was not observed in device-based physical activity data collected during the trial. One adverse event was related to the intervention. Attrition rates were low (19% at 24 months) and adherence was high. Engagement with the REACT intervention was associated with positive changes in exercise competence, relatedness and enjoyment and perceived physical, social and mental well-being benefits. The intervention plus usual care was cost-effective compared with care alone over the 2 years of REACT; the price year was 2019. In the base-case scenario, the intervention saved £103 per participant, with a quality-adjusted life-year gain of 0.04 (95% confidence interval 0.006 to 0.074) within the 2-year trial window. Lifetime horizon modelling estimated that further cost savings and quality-adjusted life-year gains were accrued up to 15 years post randomisation. Conclusion A relatively low-resource, 1-year multimodal exercise and behavioural maintenance intervention can help older adults to retain physical functioning over a 24-month period. The results indicate that the well-established trajectory of declining physical functioning in older age is modifiable. Limitations Participants were not blinded to study arm allocation. However, the primary outcome was independently assessed by blinded data collectors. The secondary outcome analyses were exploratory, with no adjustment for multiple testing, and should be interpreted accordingly. Future work Following refinements guided by the process evaluation findings, the REACT intervention is suitable for large-scale implementation. Further research will optimise implementation of REACT at scale. Trial registration This trial is registered as ISRCTN45627165. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 14. See the NIHR Journals Library website for further project information.
Citation
@article{a.2022,
author = {Stathi, A. and Withall, J. and Greaves, C. J. and Thompson,
J. L. and Taylor, G. and Medina-Lara, A. and Green, C. and Snowsill,
T. and Johansen-Berg, H. and Bilzon, J. and Gray, S. and Cross, R.
and Western, M. J. and Koning, J. L. d. and Ladlow, P. and Bollen,
J. C. and Moorlock, S. J. and Guralnik, J. M. and Rejeski, W. J. and
Hillsdon, M. and Fox, K. R.},
title = {A Group-Based Exercise and Behavioural Maintenance
Intervention for Adults over 65 Years with Mobility Limitations: The
{REACT} {RCT}},
journal = {Public Health Research},
volume = {10},
number = {14},
date = {2022},
url = {https://tristansnowsill.co.uk/a-group-based-exercise-and-behavioural.html},
doi = {10.3310/MQBW6832},
langid = {en},
abstract = {Background Mobility limitation in older age reduces
quality of life, generates substantial health- and social-care
costs, and increases mortality. Objective The REtirement in ACTion
(REACT) trial aimed to establish whether or not a community-based
active ageing intervention could prevent decline in physical
functioning in older adults already at increased risk of mobility
limitation. Design A multicentre, pragmatic, two-arm, parallel-group
randomised controlled trial with parallel process and health
economic evaluations. Setting Urban and semi-rural locations across
three sites in England. Participants Physically frail or pre-frail
older adults (aged ≥65 years; Short Physical Performance Battery
score of 4–9). Recruitment was primarily via 35 primary care
practices. Interventions Participants were randomly assigned to
receive brief advice (three healthy ageing education sessions) or a
12-month, group-based, multimodal exercise and behavioural
maintenance programme delivered in fitness and community centres.
Randomisation was stratified by site and used a minimisation
algorithm to balance age, sex and Short Physical Performance Battery
score. Data collection and analyses were blinded. Main outcome
measures The primary outcome was change in lower limb physical
function (Short Physical Performance Battery score) at 24 months,
analysed using an intention-to-treat analysis. The economic
evaluation adopted the NHS and Personal Social Services perspective.
Results Between June 2016 and October 2017, 777 participants (mean
age 77.6 years, standard deviation 6.8 years; 66\% female; mean
Short Physical Performance Battery score 7.37, standard deviation
1.56) were randomised to the intervention arm (n=410) or the control
arm (n=367). Data collection was completed in October 2019. Primary
outcome data at 24 months were provided by 628 (80.8\%)
participants. At the 24-month follow-up, the Short Physical
Performance Battery score was significantly greater in the
intervention arm (mean 8.08, standard deviation 2.87) than in the
control arm (mean 7.59, standard deviation 2.61), with an adjusted
mean difference of 0.49 (95\% confidence interval 0.06 to 0.92). The
difference in lower limb function between intervention and control
participants was clinically meaningful at both 12 and 24 months.
Self-reported physical activity significantly increased in the
intervention arm compared with the control arm, but this change was
not observed in device-based physical activity data collected during
the trial. One adverse event was related to the intervention.
Attrition rates were low (19\% at 24 months) and adherence was high.
Engagement with the REACT intervention was associated with positive
changes in exercise competence, relatedness and enjoyment and
perceived physical, social and mental well-being benefits. The
intervention plus usual care was cost-effective compared with care
alone over the 2 years of REACT; the price year was 2019. In the
base-case scenario, the intervention saved £103 per participant,
with a quality-adjusted life-year gain of 0.04 (95\% confidence
interval 0.006 to 0.074) within the 2-year trial window. Lifetime
horizon modelling estimated that further cost savings and
quality-adjusted life-year gains were accrued up to 15 years post
randomisation. Conclusion A relatively low-resource, 1-year
multimodal exercise and behavioural maintenance intervention can
help older adults to retain physical functioning over a 24-month
period. The results indicate that the well-established trajectory of
declining physical functioning in older age is modifiable.
Limitations Participants were not blinded to study arm allocation.
However, the primary outcome was independently assessed by blinded
data collectors. The secondary outcome analyses were exploratory,
with no adjustment for multiple testing, and should be interpreted
accordingly. Future work Following refinements guided by the process
evaluation findings, the REACT intervention is suitable for
large-scale implementation. Further research will optimise
implementation of REACT at scale. Trial registration This trial is
registered as ISRCTN45627165. Funding This project was funded by the
National Institute for Health and Care Research (NIHR) Public Health
Research programme and will be published in full in Public Health
Research; Vol. 10, No. 14. See the NIHR Journals Library website for
further project information.}
}