Falls and Exercise

Introduction

Elderly falls.jpg

Around a third of all people aged over 65 years fall each year.[1] This number increases to 50% of those aged 80 years or over.[1] Risk factors for falls are varied, but they include: a history of falls, weakness, poor balance, visual impairment, polypharmacy, environmental hazards and certain medical conditions, such as arthritis, depression, diabetes and incontinence.[1]

This brief video shows good falls prevention exercises.

[2]

Ageing

Aging is associated with a reduction of the functional and physiological capacity of the musculoskeletal and central nervous systems, which significantly affects motor performance . Evidence shows that these age-related declines increase the incidence of falls and re-falls among older people (one third of older adults above 65 years falling at least once a year and increasing fall rates in even older ages). Falls in older adults occur mainly during dynamic daily tasks.[3]

However falls are not a normal part of ageing. Ageing is not considered a cause of disability until a person is over 94 years. However, problems can arise earlier for the following reasons:

  1. Disease – 84% of which are preventable by improving diet, exercising more and adopting healthy lifestyle behaviours – these preventable diseases include cardiovascular disease, stroke, type 2 diabetes, dementia and depression[4]
  2. Loss of fitness and de-conditioning
  3. Negative beliefs about growing older[4]

Inactivity typically increases with age. At 75-84 years, 47% of all adults are inactive. This number increases to 70% in those aged over 85.[5] This drop in activity contributes to the huge number of falls in this age group.[4]

  • Inactivity is defined as 30 minutes or less of moderate to vigorous activity per week.[4]

Active Lives Adult Survey - Chief Medical Officers' (CMO) Guidelines

The CMO guidelines set out the minimum threshold for well-being

  • 150 minutes of moderate exercise per week
  • OR 75 minutes of vigorous exercise
  • 2 strength sessions per week
  • 2 balance sessions per week
  • Reduce sedentary behaviour[5]

These guidelines should be considered a target as many older adults are doing much less. Our aim as physiotherapists is to encourage older adults to slowly build up their activity levels to the levels outlined above.

Why Exercise?

Falls are a common reason for admission to hospital in older adults. However, the most harm occurs when a frail older adult falls. This is because “weak fallers” tend to get stuck on the floor. Exercise helps to preserve and build muscle, thus reducing the risk of falling.

The problems associated include:

  • Hypothermia
  • Confusion
  • Tissue viability issues
  • Pressure sores
  • Dehydration
  • Hospital stay

Inactive older adults also have greater muscle atrophy. Muscle tissue usually provides padding, protects joints and preserves bone density. Thus, weak fallers tend to fracture bones more easily. A cross-sectional study suggested that the older inpatient showed an increase in the intramuscular quadricep muscle adipose tissue approx 1.7 times that of the healthy older individuals. Also, the study observed increased intramuscular adipose tissue with older inpatients who were unable to walk independently as compared to older inpatients who were able to walk freely[6].

They also require more care both during a hospital stay and in the community, which adversely affects quality of life. Exercise can help to address these issues.

A Systematic Review of Randomized Controlled Trials[7] suggested that a low dose of creatine monohydrate along with resisted exercises may improve upper and lower extremities strength in healthy older adults. A randomised controlled trial (RCT) found RESPOND; a telephone-based falls prevention program with a person-centered approach was found to be useful at reducing the rate of falls and fractures compared with usual care, but not fall injuries or hospitalisations[8].

Comparing Exercise and Physical Activity

Physical activity refers to any activity that increases heart rate, breathing rate and energy demands.

Exercise is a more targeted activity designed to increase fitness. It can be defined as a structured form of physical activity designed to improve fitness and well-being.

It is important that a patient understands the distinction between physical activity and exercise. We need them to increase their physical activity generally, but exercise is a targeted intervention to reduce the risk of falls. An older adult needs to do both.

The Guidelines

NICE Guidelines

The NICE guidelines recommend strength and balance training should be included in a falls prevention programme. They should be individually prescribed and monitored by a trained professional. This is because exercise is dose-dependent and needs to be set at a suitable level for it to be effective.[9]

Falls and Fracture Consensus Statement

The Falls and Fracture Consensus Statement recommends that most community-dwelling older adults with a low to moderate risk of falls should participate in an exercise programme that includes strength and balance training.[1]

To be effective, this programme needs to be at least 50 hours, with two or more sessions per week.[1]  Group programmes can be supplemented with home exercise programmes.

When creating a programme, it is important that challenging balance exercises are included in order to achieve strength and balance adaptation.[1]

While walking is beneficial in general, it should not be included in programmes for older adults who have a high risk of falling, as it may result in further falls[1].

At the end of the 50-hour programme, the patient should be referred on for maintenance classes that suit their needs and abilities,[1]

Cochrane Review

A Cochrane Review, "Exercise for preventing falls in older people living in the community" found that exercise programmes:

  • reduce falls rate (by 23%)
  • reduce the number of people experiencing more than one fall (by around 15%)
  • and may reduce the risk of fractures (by 27%)[10]

An exercise programme must consist of mainly balance and functional exercises. This review could not determine how effective resistance exercise is in isolation and also notes that walking is not an effective strategy to reduce falls risk.[10]

Physical Activity – A Population Strategy

Exercise older person.jpg

How can we as physiotherapists promote physical activity more broadly?

  • Provide a variety of options for older adults
  • Encourage active travelling[11] – it is also necessary to consider practical, environmental issues like the availability of public toilets and the quality of pavements
  • Promote the benefits of physical activity on social media
  • Encourage active work places – for example, encourage the use of stairs, or cycle to work schemes. This is important as more adults of working age are showing signs of frailty/pre-frailty.[4] If we can encourage activity in working age adults, they may continue these positive health behaviours into their retirement

Key findings of a 2018 review were

  • Physical exercise clearly reduces the follow-up risk of falling.
  • Exercise interventions for fall prevention may include stability-challenging conditions and perturbations.
  • Specification of such exercises (alongside intensity) and understanding of their physiological underlying effect is needed to ensure and improve effective retention of fall-related exercise benefits in the post intervention follow-up[3].

Summary

  1. Exercise and physical activity are complementary
  2. Variety and patient choice are key
  3. We need to maximise independence – if an older adult has greater strength, better balance and endurance, they will be more independent and their risk of falls will reduce
  4. The evidence is that physical exercise interventions have the potential to significantly reduce fall rates and risk in healthy older adults. Posture-challenging exercises in particular should be considered when designing fall prevention interventions[3].

As health professionals we need to:

  • Promote exercise and activity at every contact
  • Be certain when we are promoting exercise – it is a very effective intervention, so we need to highlight this
  • Be careful with the language we use. For example, phrases like “young at heart”, “take it easy” or “don’t take the stairs” can reinforce the belief that exercise is harmful and only for younger people
  • Collaborate and share learning, facilities, staff and resources

For more information on the problem of falls in hospital and potential ways to address this, check out this video from Chris Tuckett:

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Public Health England. Falls and fracture consensus statement. Public Health England, 2017: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/586382/falls_and_fractures_consensus_statement.pdf
  2. Chartered society of Physiotherapy Falls prevention exercises - Older People's Day Available at: https://www.youtube.com/watch?v=n8s-8KtfgFM&t=36s (last accessed 27.11.2019)
  3. 3.0 3.1 3.2 Hamed A, Bohm S, Mersmann F, Arampatzis A. Follow-up efficacy of physical exercise interventions on fall incidence and fall risk in healthy older adults: a systematic review and meta-analysis. Sports medicine-open. 2018 Dec;4(1):56.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292834/ (last accessed 11.1.2020)
  4. 4.0 4.1 4.2 4.3 4.4 UK Active. Reimagining ageing. London: UK Active, 2018 (https://www.ukactive.com/reports/reimagining-ageing/)
  5. 5.0 5.1 Department of Health and Social Care, Physical Activity Guidelines: Infographics. 2019. Available from: https://www.gov.uk/government/publications/physical-activity-guidelines-infographics [Accessed 3rd October 2019].
  6. Akazawa N, Okawa N, Kishi M, Hino T, Tsuji R, Tamura K, Moriyama H. Quantitative features of intramuscular adipose tissue of the quadriceps and their association with gait independence in older inpatients: A cross-sectional study. Nutrition. 2020 Mar 1;71:110600.
  7. Stares A, Bains M. The Additive Effects of Creatine Supplementation and Exercise Training in an Aging Population: A Systematic Review of Randomized Controlled Trials. Journal of geriatric physical therapy (2001). 2019 Feb.
  8. Morris RL, Hill KD, Ackerman IN, Ayton D, Arendts G, Brand C, Cameron P, Etherton-Beer CD, Flicker L, Hill AM, Hunter P. A mixed methods process evaluation of a person-centred falls prevention program. BMC health services research. 2019 Dec 1;19(1):906.
  9. National Institute for Health and Care Excellence (NICE), Falls in older people: assessing risk and prevention [CG161]. Available from: https://www.nice.org.uk/guidance/cg161 [Accessed 3rd October 2019]
  10. 10.0 10.1 Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson et al.  Exercise for preventing falls in older people living in the community. (Cochrane Review) Cochrane Database Syst Rev 2019; (1): CD012424 (https://www.cochrane.org/CD012424/MUSKINJ_exercise-preventing-falls-older-people-living-community)
  11. National Institute for Health Research, Moving matters: Interventions to increase physical activity. NIHR Dissemination Centre, 2019 (https://www.dc.nihr.ac.uk/themed-reviews/Moving-Matters-FINAL-WEB2.pdf)