Implications for Exercise to Prevent or Reduce Falls in the Elderly Population
With the expanding population of older adults, falls, which are closely associated with considerable mortality, morbidity, and medical expense, have aroused much attention regarding concerns about reducing and preventing fall events in elderly individuals. This literature review discusses intrinsic and extrinsic contributing factors of fall events and presents some specific types of exercise programs beneficial for older adults. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[11]:30-34)
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A rapidly expanding aging population is one of the factors that will impact healthcare services around the globe. According to statistics from the U.S. Bureau of the Census,1 the population of older people who are age 65 years or older numbered 35 million in 2000 and represented 12.4% of the U.S. population. By 2030, there will be approximately 70.3 million older adults, representing almost 20% of the entire population. Accordingly, research focused on older adults, especially regarding how to promote successful aging and enhance the overall quality of life in the older population, has garnered much attention in recent years.
Specifically, an increased possibility of falls has been a serious problem associated with the process of aging.2 About 35% of older people living in the community are likely to fall at least once in a year, and about 10% of these falls result in severe injuries, fracture, and head trauma.3 In addition, falls have been identified as significant contributors to decreased physical and social functions and to increased risk of long-term care (LTC) facility admission.4 Well-designed and appropriately implemented intervention programs may yield vital information in geriatric practice and research.
The purpose of this review article is to identify and investigate risk factors for falls, including intrinsic and extrinsic factors, and to discuss a variety of therapeutic and preventive approaches that have been utilized to reduce the number of fall incidents in older adults.
Risk Factors
Risk factors for falls are generally classified into two categories: intrinsic and extrinsic factors. The following sections will investigate some specific risk factors in each category and discuss some recent research findings.
Intrinsic Factors
Intrinsic risk factors relate to the individual and are typically associated with medical diagnosis, medication effects, and some age-related physiological changes.5
Age. Age has long been considered as a strong risk factor for falls among older adults, especially for people over age 85.6 Specifically, Stolze and colleagues7 confirm from their longitudinal investigation that age is not only an important risk factor for ordinary community-dwelling older people, but also has significant effects on fall events among neurological inpatients. Furthermore, McGibbon and associates8 explored falls from biomechanical perspectives and support the tremendous effects of aging on falls. Results from this study suggest that some age-related changes in the control of lower trunk movement during gait requires higher mechanical energy demands of lower trunk musculature, and therefore may reduce the ability to recover from dynamic instability.
Medical diagnosis. Disease-related changes, which impair central processing, neuromotor function, vision and vestibular function, proprioception, musculoskeletal, and systemic function, precipitate the occurrence of fall events, especially among the elderly.9 For example, arthritis, diabetes, Parkinson’s disease, cardiovascular disease, dementia, peripheral vascular disease, and gait and balance disorders have long been identified as risk factors for falls.
Depression. The chances of falls are more than 30 times greater for persons with depression than those without depression.10 Various research studies have confirmed the significance of depression in fall events. For example, in a Dutch prospective study conducted in community-dwelling elderly persons, depression is identified as one of the four predictors for recurrent falls.11
History of previous falls. Nursing home (NH) residents with fall history are more than three times more likely to fall than residents without previous falls.6 Similarly, Rubenstein and Josephson12 confirmed that past history of falls is also one of the most common intrinsic fall risk factors among community-living elderly persons.
Use of medications. Much evidence exists in the current literature supporting the association between medications and falls. Specifically, certain medications such as psychotropics, antidepressants, and cardiovascular agents have aroused much attention. For example, Landi et al13 found that psychotropics, antipsychotic agents, and benzodiazepines are associated with increased risks of falls. Similarly, treatments with antidepressants, neuroleptics, and cardiovascular medications are identified as risk factors in neurological inpatients.7
Extrinsic Factors
Extrinsic risk factors usually refer to certain environmental or weather conditions that contribute to falls. Poorly-fitted assistive devices, clothing, or footwear are also included in this category.5
Environmental hazards. Environmental constraints, such as uneven walking surfaces, stairs, slippery floors, low seats, and poor lighting, interfere with functional stability in the elderly and increase the probabilities of fall events.14,15 Specifically, Rubenstein and colleagues16 found that environmental hazards account for 16% of NH falls. Similarly, a group of Italian geriatrics researchers utilized a national home care database and detected, among community-dwelling older populations, that people living in an unsafe place with environmental hazards have increased risks for falls.17
According to the Centers for Disease Control and Prevention, approximately 50-67% of falls occur in or around home, and environmental hazards contribute to more than half of home falls. Additionally, with the introduction of the concept of “aging in place,” more elderly people choose to age in local communities instead of LTC facilities. Geriatrics professionals face severe challenges to implement some interventions to reduce falls, or at least minimize fall-related injuries. Although environmental modification theoretically seemed attractive, evidence proves that isolated environmental modification were ineffective in preventing or reducing fall events.18 Therefore, it is crucial to include the significance of environmental hazards of falls in family, resident, and staff education; to incorporate a home safety assessment identifying unsafe environments in a multifactorial fall management program; to apply some technologies, such as high-low beds and defined-perimeter beds, to diminish the severity of fall injury; and to integrate other fall prevention strategies to decrease the risks of fall events.
Footwear. As alterations in balance and gait have long been identified as significant contributors of falls among the elderly,19 the indirect effects of footwear act via the state of balance and gait and have aroused much attention. For example, Lord and Bashford20 studied the direct impact of footwear on balance in a group of older women. Balance was measured in postural sway, maximal balance range in the anterior-posterior direction, and coordinated stability. Women with flat shoes or bare feet performed better than in high-heeled shoes. Similarly, Arnadottir and Mercer21 compared the performance of a group of older women in three functional performance tests in walking shoes, dress shoes, or bare feet. Results show that the type of footwear significantly affected the performance on these functional performance tests. Accordingly, footwear intervention is strongly suggested to be considered as a way to enhance balance and gait or to reduce fall events or functional decline among the older population. Specifically, athletic and canvas shoes are recommended top choices since they are least associated with falls.18
Assistive devices. Because of the decreased ability in controlling the flexing trunk, older adults are more susceptible to balance loss and falls, especially balance-impaired older people.22 Assistive devices, such as canes and walkers, promote stability and control of trunk repositioning by augmenting the base of support, offering proprioceptive stimulus, and redistributing body weight.18 However, improper use of assistive devices without the guidance under a trained professional might increase the risk for falls.14 Therefore, it is important for elder care professionals to choose the correct size and type of assistive device for frail older adults and include sufficient instructions in its safe use.
Fall Prevention or Reduction Programs
Much evidence exists in the current literature supporting the effectiveness of multifactorial intervention programs that incorporate intrinsic and extrinsic factors to decrease falls. For example, the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention23 published some differentiated multifactorial interventions for community-dwelling older persons, LTC residents, and in-hospital patients. Specifically, they suggest fall interventions among community-dwelling persons should include: gait training and advice on assistive devices, review of medication usage, exercise programs, treatments of postural hypotension, modification of environmental hazards, and cardiovascular disease treatments.
In the interest of space limitation, this article will not explore the overall multifactorial fall prevention programs but will examine one of the specific components: exercise interventions. Some specific exercise programs identified as beneficial for fall prevention from previous studies will be discussed, and further implications and suggestions will be explored.
Exercise Programs
Exercise refers to planned, structured, and repetitive bodily movement that is done to improve or maintain one or more components of physical fitness, and it is a subset of physical activity.24 The benefits of exercise have long been documented in the literature. For example, exercise in the elderly can help maintain their activities of daily living, socialization, and self-esteem; increase muscle strength, flexibility, and endurance; and improve overall quality of life.25
Exercise has been identified as the most potentially important component of community-based multifactorial intervention programs and might also be an effective single intervention.26 Much supportive evidence could be retrieved from the current literature. For example, the Study of Osteoporotic Fractures Research Group27 has shown that physical activity is strongly related to a reduced risk of hip fracture in older women. Active women had a statistically significant reduction of 42% in the risk of hip fracture as compared with sedentary women. As most hip fractures result from falls,28 the benefits of exercise to hip fracture reduction can indirectly impact the risks for falls, and therefore prevent or reduce fall events. Similarly, Hill-Westmoreland and associates29 conducted a meta-analysis of 12 intervention studies of fall prevention and found that the mean weighted effect size of exercise alone is 0.0220. As the overall mean weighted effect size for the studies included in this study is 0.0779, it can be observed that exercise alone plays a crucial single role in the prevention or reduction of falls.
Although researchers have conducted various kinds of exercise intervention programs to prevent or reduce falls among older populations, the optimal type, duration, and intensity of the exercise program are still to be determined.18 Robertson et al30 assessed the effectiveness of a nurse-delivered exercise program, which consists of a set of muscle strengthening and balance retraining exercises for 8 weeks, at a community health agency in New Zealand. Results showed this exercise program to be effective in reducing falls among the older participants and that it is cost-effective for application in larger, older populations. Schoenfelder31 explored the role of exercise, specifically the effectiveness of an ankle strengthening and walking program for 3 months, in preventing falls among LTC residents. Findings from the intervention group suggest that regular exercise shows promise for preventing deterioration and improving fall-related outcomes.
Furthermore, although specific optimal exercise types to prevent or reduce falls still remain unclear, some balance training, such as Tai Chi, appears to be a promising option.9 The research group of the Atlanta Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trial32 conducted a prospective, randomized, controlled clinical trial and compared the effects of Tai Chi and computerized balance training on frailty outcomes in older adults. Results showed that moderate Tai Chi intervention can impact favorably on some biomedical and psychosocial indices of frailty and have favorable effects upon fall events. Additionally, Tse and Bailey33 demonstrated that regular Tai Chi practice dramatically promotes participants’ balance control and improves the abilities of postural control. As the ability to maintain postural positions or balance is significant in fall prevention, it is reasonable to conclude that regular Tai Chi practice may favorably impact the occurrence of falls.
Although studies mentioned above have proved to be effective in preventing or reducing falls, the specific modalities of exercise programs, duration, or intensities are totally different. Researchers can hardly reach an agreement on the optimal specific exercise program that would be most beneficial in preventing or reducing falls among older adults. However, following are some general guidelines for prescribing exercise programs for elderly persons to prevent or reduce falls that can be helpful for geriatrics professionals:
Warm-up and cool-down. Warm-up and cool-down periods should be longer in older adults.25 Adequate warm-up allows a gradual redistribution of blood to the muscles and makes the musculoskeletal and cardiorespiratory systems ready for exercise; sufficient cool-down activities can gradually lower the exercise-induced heat load and peripheral vasodilation. Optimal warm-up activities should last 15-20 minutes, while 10-15 minutes should be devoted to the cool-down period. Both periods should involve primarily large muscle groups, such as calf and hamstring, and typical warm-up and cool-down exercises may include bent-knee sit-ups, shoulder shrugs, presses, and circles.34
Intensity. The intensity of exercises can be monitored on an individual basis or a combination of several physiological parameters, such as heart rate, rate of perceived exertion, and energy expenditure.25 For example, exercises can be assessed to goals of 40-70% of maximal heart rate.
Frequency. The guidelines published by American College of Sports Medicine35 are appropriate for use among the elderly, and include:
• Less than 3 Metabolic Equivalents (METs): 5 minutes of exercise several times daily
• 3-5 METs: at least twice daily as tolerated
• More than 5 METs: 3 times per week on alternate days
Rate of progression. The exercise progression goes from conditioning to improvement to maintenance.25 Conditioning-phase exercise starts with low-level aerobic activities for 3 minutes to the goal duration of 10-15 minutes, and this phase usually lasts 4-10 weeks. In the improvement phase, both the duration and intensity increase from conditioning. Exercise duration of this phase is about 20-30 minutes, and the entire phase can last 4-6 months. Finally, the maintenance phase keeps the routine of the improvement phase, or until other more enjoyable activities can be substituted.34
Rest periods and physical environments. Longer rest periods between exercise sessions and safe physical environments are important for older adults.25 Longer resting time is necessary for the heart rate to return to resting level, and appropriate environments are vital to avoid dehydration, hypothermia, or hyperthermia.
Conclusion
Fall events are closely associated with considerable mortality, morbidity, and significant negative life events.4 Falls among the elderly have become not only a concern of geriatrics professionals, but also have received much attention from society.
Some intrinsic and extrinsic risk factors contribute to the etiology of falls and highlight the need for effective fall prevention programs. Exercise is an important single component, with Tai Chi a promising option. The optimal type, duration, and intensity of exercise that would be beneficial to prevent or reduce falls among older persons are still unclear.
Finally, some important implications for clinical care of the elderly population may be drawn from this article. First, geriatrics care focusing on fall prevention or reduction should be comprehensive and individualized. Healthcare staff should not only be familiar with knowledge about fall risk factors, but also assess these factors on a regular basis. Thus, older people with high risks can be easily identified, and effective strategies can be implemented in a timely manner to prevent falls, or at least to reduce the severe outcomes of falls. Secondly, although specifics about beneficial exercise programs are still unclear, because exercise plays a significant role in fall management, older adults are strongly encouraged to participate in some moderate balance exercise, such as Tai Chi, or just to keep physically active. It is vital for geriatrics professionals to follow exercise guidelines when advising exercise modalities for older populations to maximize the exercise benefits and effectively address the severe outcomes of falls.
The author reports no relevant financial relationships.
Acknowledgments
The author thanks Dr. Marilyn Rantz, Sinclair School of Nursing, University of Missouri, Columbia, MO, for her guidance and support, and Dr. Kathryn Burks, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, for her help with manuscript preparation. My gratitude also goes to Dr. Kathleen Gilchrist and Ms. Audrey Cochran, Bakersfield, CA, for their encouragement and support.
Dr. Yu is Assistant Professor, Robert & Edith Cochran Endowed Professor of Gerontology, Department of Nursing, California State University, Bakersfield.
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