In Balance: Weighing the Outcomes: Evaluating Fall Prevention, Physical Activity, and Functional Status in Older Adults

The primary aim of my thesis was to assess the (cost-)effectiveness of the In Balance fall prevention intervention and evaluate how its implementation can be further optimized. In addition, we initially investigated associations between falls and fall-related injuries on the one hand and physical activity and functional status on the other hand. Below follows a brief summary of this thesis per chapter, followed by general considerations regarding my findings with respect to the aims and within the general context of fall prevention. Chapter 1 introduces the background and rationale for this work. Falls among older adults significantly impact their independence, quality of life, and healthcare costs. Fall prevention interventions can help mitigate these risks. Moreover, the associations between falls, physical activity, and functional status remain unclear and were explored in this thesis. Chapter 2 examined the relationship between physical activity, falls, and fractures, using data from 311 participants aged 75 and older in the Longitudinal Aging Study Amsterdam. No statistically significant association was found between physical activity and fall risk or fractures, and frailty did not modify these associations. Despite these findings, fall risk should still be considered in physical activity recommendations for older adults. Chapter 3 presented the study protocol for a multicenter randomized controlled trial (RCT) that investigated the effectiveness and cost-effectiveness of the In Balance program compared to usual care. The program, aimed at community-dwelling older adults with increased fall risk, consists of a 14-week intervention including Tai Chi–inspired exercises and education. Primary outcomes were falls and injuries over 12 months; secondary outcomes included physical performance, activity, confidence, health status, quality of life, and costs. A process evaluation was also included. Chapter 4 analyzed whether physical performance measured by the Short Physical Performance Battery (SPPB) correlated with real-life gait quality and quantity, using wearable sensors. Among 229 participants, correlations were weak (< 0.3), suggesting that SPPB and sensor-based data reflect different aspects of mobility. Combining both may offer a more comprehensive view of functional status. Chapter 5 reported the effectiveness outcomes of the In Balance intervention. The intervention group experienced fewer falls (1.67 vs. 1.98 per person/year) and fall-related injuries (0.70 vs. 0.97), though differences were not statistically significant. Some improvements in balance, strength, and emotional wellbeing were observed, but also not significant. The lack of power due to smaller-than-expected group differences might explain these results. The most benefit appeared during the intervention period, highlighting the potential value of ongoing support post-intervention. Chapter 6 explored cost-effectiveness. While the In Balance group had slightly lower costs and gained more Quality Adjusted Life Years (QALYs), the differences were not statistically significant. Nonetheless, cost-effectiveness modeling showed that In Balance was likely to be cost-effective, even at low willingness-to-pay thresholds, with a 98% probability of being cost-effective at a willingness-to-pay of €0. Chapter 7 presented the process evaluation. High satisfaction was reported among participants (93%) and therapists (86% would recommend the program). Six key themes emerged for sustainable implementation: (1) recruiting and motivating participants, (2) structure and content of the program, (3) awareness and perceived effects, (4) social interaction, (5) funding, and (6) long-term continuation. These insights led to practical recommendations for optimizing implementation, relevant not only for In Balance but also for other fall prevention programs.