Fall-related injuries among older adults are a significant and growing public health concern. Over one-quarter of community-residing men and women 65 years of age and older fall annually [1,2]. Risk is compounded over time as a single fall predicts recurrent falls [3-7], and fall-related mortality has increased over 30% just between 2007 and 2016 [8]. Not only do falls represent a major cause of accidental death and mobility-related disability among older adults, but they also result in psychological distress, loss of independence, and a decrease in quality of life [9,10]. Despite the existence of various interventions and policies aimed at reducing fall risk in this population, the incidence of falls remains alarmingly high.

While fall risk is multifactorial, identification of risk factors, as well as referral to and participation in appropriate fall-risk reduction programs are established as an effective, evidence-based approach to reduce fall risk [2,11]. Specifically, targeted strength and balance exercises have consistently been shown to improve fall risk, and accordingly, the Centers for Disease Control and Prevention (CDC) has outlined an evidence-based clinical approach to identify those at risk for falls to help assess known risk factors and refer for community-based fall-prevention programs [12,13]. The public health use of this approach is further supported by the United States Preventive Services Task Force (USPSTF) “Grade B” recommendation to refer older adults for fall prevention exercise programs [14,15]. However, despite these resources and recommendations, clinical identification and referrals have been insufficient [16]; only approximately one-third of older adults report being asked about fall-risk by their health care providers, and similarly, only around a third of those who fall report discussing their fall and fall circumstances with their health care provider [17,18]. At the population level, conservative estimates suggest far fewer than 50% older adults meet recommended physical activity levels [19]. These findings mirror the growing epidemiological evidence of increased rates of falls in older adults. While some existing programs that improve fall risk and activity for older adults, including EnhanceFitness PA and Silver Sneakers may be available to some older adults with certain insurance plans at no additional costs [20], others may face substantial fees; furthermore, many eligible seniors do not use these programs, citing several barriers. Such barriers include general dislike of gyms and a lack of awareness or instructor suitability and generalizability, problems accessing appropriate classes, concerns about bad weather and driving, and perceptions about being “old” in these environments [21]. These issues are even greater among older adults residing in areas and communities that have fewer facilities for guided physical activity, more limited transportation infrastructure and less exercise expertise [22]. Finally, there remain geographic and demographic disparities related to falls, including higher rates in rural areas [2], highlighting the interest and need for different approaches to address this public health and clinically relevant problem in older adults in novel ways that increase reach and are safe and effective.

Appropriate technologically driven approaches have promise to increase range and dissemination of fall prevention resources, including making them easier and safer to access [23]. Furthermore, digitally delivered programs that involve appropriately tailored exercises offer the opportunity to balance risks and benefits during times of social distancing, while improving dissemination and community uptake, and possibly improve fall risk [24]. While recent attention has highlighted concerns with broadband access in older adult populations, especially with attention to disparities and equity [25], digital interventions showcase the promise as those aged 65 years and older still represent the fasting growing demographic in technological uptake [26,27]. Thus, given the trend of increasingly ubiquitous access to smart-enabled technology in older adults, and gaining acceptance in this population [26], there is great potential to improve equitable access to high-quality exercise-based fall prevention resources by decreasing geographic boundaries—not only immediately, but increasingly in the future. Alternative approaches, including prerecorded, online, and asynchronous delivery, are an additional consideration but lack the ability for real-time guidance, which is possible with synchronous real-time delivery, and therefore offer the opportunity to provide guidance with risk mitigation and personalization when appropriate for participants. Therefore, approaches that leverage technology to improve access to fall-risk reduction exercise programs are imperative, and growing data suggest digitally formatted delivery may be feasible [28].

Zoom (Zoom Video Communications) is a user-friendly, web-based service that provides digital video-based connections between multiple users; Zoom-for-Telehealth is a HIPAA-compliant encrypted service used for clinically delivered care and permits conferencing between individuals. Zoom is readily available online, free to download, and supports a one-to-many viewing platform such that it can be set up so that only the host can see individual participants at a given time [29]. This application was selected based on the ubiquitous nature and availability to host professionally through our institution. The nature of this digital platform lends interest in understanding how fall-prevention curricula may be developed and delivered to older adults; therefore, we developed a novel digital platform, Strong Foundations, designed to leverage the advantages of digital technology with evidence-based fall-prevention strategies, along with real-time feedback to users based on appropriate or inappropriate practice, optimizing gains for a larger group and highlighting core exercises. This program includes features to promote adherence, engagement, and social connectivity enabled by real-time interaction, all important to promote efficacy and subsequent improvement in gains from any intervention [30]. Given the novelty of such a program, we aim to understand the feasibility of this 12-week program in terms of usability and acceptance using a validated scale and attendance rates and explore measures of digitally collected physiologic improvement in adults aged 60 years and older.

The development and rationale behind the need for a digital curriculum, Strong Foundations, is described here. In this 12-week pilot, we found a high level of usability and feasibility of this program based on the high attendance rates, SUS scores, and self-reported participant experience. In addition, we found impressive changes in digitally collected measures of functional improvement in most participants, suggesting that the program increased strength and mobility and may reduce the risk of falls. Clinically, the 8%‐20% improvement in measurement after 12 weeks is notable, especially considering recruitment generally was limited to those with limited risk factors for falling and have higher levels of function and therefore less scope for improvement or gain. While exploratory in nature, these gains are promising to show improvements across this intervention even in a relatively lower risk group of older adults.

This 12-week fall prevention program was well accepted and showed promise related to reducing fall risk in an older adult population. The usability and safety (as evidenced by no adverse events) of the program indicates that digitally delivered real-time exercise instruction has potential in this population to reduce barriers and increase availability of fall prevention programs. While those enrolled were relatively low risk for falls (as evidenced by the STEADI score used for eligibility), results should be contextualized that even those who were generally doing reasonably well have opportunity to improve. Indeed, in other populations, such as older adults with hip osteoarthritis, a change in TUG of around 1 second and a 30-second chair stand of around 1 second and 2 stands, respectively as meaningful [46], and between 0.9s and 6.0s depending upon the quality of life assessment tool in patients who were postoperative [47]. While our results of TUG change of 0.8 seconds (normal) is less than these noted changes, given the health status of our enrolled participants and limited 12-week intervention, the improvements are still notable. Furthermore, our improvement of 3.5 stands in 30 seconds, especially from a baseline of 14.5 stands—a notable good baseline—shows the resilience and opportunity for improvement in lower extremity strength regardless of starting health status.

However, this study is not without limitations. This project recruited heavily from an environment with a relatively high socioeconomic status. As such, there may be a bias in enrolling individuals who already have digital tools like smartphones, tablets, and laptop computers and a high level of experience with digital technology, and therefore, a better understanding how to use these systems. As such, these participants may not be representative of the larger older adult population who may not have the same level of access to or understanding of such digital systems. We also did not ask specifically about their experience with previous technologies, though participants all did have sufficient equipment for enrollment. We also primarily enrolled women, which limits interpretability and generalizability of findings, especially given recent data suggesting higher fall-related impairment among older adult men [2]. Despite this, the use of a validated scale focused on usability commonly used across several domains related to eHealth and technology deployments [48], findings related to usability are supported; however SUS deployment in older adults has been challenged in some situations, namely those with cognitive impairment [49]. While we did not specifically screen for this in our enrollment, it is possible findings may be diluted. Furthermore, while the reasons remain unclear, the SUS average may be different and higher in digital physical activity interventions [48], making contextualizing results important; although, such data in older adult subpopulations remain limited. While we also did not only enroll participants who had experience with Zoom, it is possible that interested individuals may not have expressed willingness to enroll who were otherwise intimidated by such platforms, although we did not anecdotally experience this feedback. Subjective survey experience reports should be interpreted with this consideration [27]. Finally, it is not clear if digitally collected measures of physical performance, specifically the TUG and 30 second chair rise, are valid and reliable when compared with measures gathered in the clinic or laboratory. As such, the changes in physical performance demonstrated here, while promising, should be viewed as preliminary and not necessarily indicative of the same degree of change as would be expected were the data gathered in a more traditional context. However, given the rate of technology availability has continued to increase, attention is warranted to understand how these interfaces may be used for older adults [27].

In conclusion, this pilot showed that a digital interface is both usable and feasible but also suggested promise at improving functional measures associated with fall risk. Based on the increasing yearly number of falls and the relatively small number of participants who are engaging in fall-prevention programs, it seems clear that existing in-person exercise delivery modalities are insufficient. Strong Foundations offers a safe alternative to provide a real-time fall prevention program. Furthermore, the real-time feedback likely provides participants with added sense of purpose and value in their investment in improving their functional ability and therefore provide increased motivation for sustained behavior. Given the growing population and epidemiology of falls, having numerous options that enable engagement of older adults into high quality exercise programs designed to improve strength, postural alignment, and balance is increasingly important. Strong Foundations has promise to augment existing opportunities in this population and further leverages digital tools to increase the breadth of delivery potential. Ongoing attention and research is needed to both understand the scalability and sustainability of this program and to confirm that the observed changes in function and mobility through validated laboratory-based methods are replicated.