Physical Activity, Older
People and Falls: Research
Update
• The effects of ageing on performance
• Exercise to prevent falls
• Holistic benefits of exercise
• Inactivity in the UK
• Exercise as part of a multifactorial intervention
Specialist PSI Exercise Module
AGEING AFFECTS ALL OF US
1-2%
in functional ability p.a.
– Strength
– Power
– Bone density
– Flexibility
– Endurance
– Balance and co-ordination
– Mobility and transfer skills
Sedentary behaviour accelerates the loss
of performance...
Specialist PSI Exercise Module
QUADRICEPS STRENGTH
Men
Women
10
8
6
Threshold
level of
strength for
independence
4
2
70-74
65-69
60-64
55-59
Age
(years)
50-54
70-74
65-69
60-64
55-59
0
Strength to be confident of rising
from low chair without using arms
50-54
Knee extension strength (N/kg)
12
Specialist PSI Exercise Module
FUNCTION FOR LIFE
 Wash hair comfortably?
 20% women & 14% of men > 50 do not have
sufficient shoulder flexibility
 Confident of getting out of a chair without using arms ?
 25% women & 7% men aged 70 – 74 do not
have sufficient leg strength
 Ease of stair use?
 47% women aged 70 – 74 do not have
sufficient leg power
 Walk comfortably at a 20 minute a mile pace?
 Nearly 10% men & over 35% women aged 50 –
74 do not have sufficient aerobic capacity
 35% men and 80% women aged 70 – 74
Specialist PSI Exercise Module
Sedentary vs active lifestyles
• >3 hrs per week targeted exercise
– myocardial infarct - 3 x less likely
– Osteoporosis - 2 x less likely
– Fall-related injuries & Hip fracture - 2 x less likely
• WHO, 1996 “regular physical activity helps to
– “preserve independent living” and
– “postpone the age associated declines in balance and coordination that are major risk factors for falls”
– WHO, 2011 “physical activity (for 65+ year olds)
– improves cardiorespiratory and muscular fitness, bone and functional
health, and reduces the risk of NCDs, depression and cognitive decline”
Specialist PSI Exercise Module
Exercise to Prevent Falls
Exercise could help fallers in a number of ways:
• Reducing Falls (or injurious falls)
• Reducing known Risk Factors for Falls
• Reducing Fractures (or changing the site of fracture)
•
•
•
•
Increasing Quality of Life & Social Activities
Reducing Fear
Reducing Long Lies
Reducing Institutionalisation
Specialist PSI Exercise Module
Fracture Prevention Triangle
Exercise can
increase BMD and
alter bone
properties
Exercise can
reduce falls
FALLS
FRAGILITY
FRACTURE
Exercise can
increase muscle
strength (padding)
and improve
reaction times
FORCE
Specialist PSI Exercise Module
Specificity of Exercise to Reduce Falls
Province, 1995
Group and individual balance and strength training
>65’s
Wolf, 1996
Group Tai Chi >65’s
(NOT >70’s at risk, Wolf 2003)
Campbell, 1997
Home-based exercise >80’s
Robertson, 2001
Home-based exercise >65’s and >80’s
Day, 2002
Group exercise >70’s at risk
Barnett, 2003
Group exercise >65’s at risk
Lord, 2003
Group exercise >60’s retirement village
Means, 2003
Group exercise >65’s, psychosocial effects
Liu-Ambrose, 2004
Group exercise for >75s with low bone mass
Skelton, 2005
Group exercise >65’s frequent fallers
Specialist PSI Exercise Module
Not “ALL” Exercise works to
Prevent Falls
Effective
Ineffective to prevent falls
but effective on falls
risk factors…………
Barnett 2003
Lord 2003
Morgan 2004
Skelton 2005
Buchner 1997
Campbell 1997
Campbell 1999
Cornillon 2002
Day 2002
Robertson 2001
Wolf 1996
Bunout 2005
Campbell 1999, 2005
Carter 2002
Ebrahim 1997
Latham 2003
Lord 1995
McMurdo 1997
Mulrow 1994
Pereria 1998
Reinsch1992
Schnelle 2003
Steinberg 2000
Wolf 2003
• Insufficient tailoring
• Insufficient duration
• Too much time seated
• Not an emphasis on
strength and balance
• Not delivered by trained
personnel
• Not progressive
• Not intensive enough
Specialist PSI Exercise Module
Effective Duration of Exercise
Provision / Benefit
• Strength, Power, Static balance, Gait
8-12 wks
• Dynamic balance, Endurance
12-24 wks
• Bone strength (hip, spine and wrist)
36+ wks
• Dizziness and Postural Hypotension
24+ wks
• Transfer skills
24+ wks
• Mood, Depression, anxiety, self-esteem
12+ wks
• Falls
15-52 wks
Specialist PSI Exercise Module
Interventions in the
community
• Update of 2009 review
• 159 trials with 79,193
participants
• most common
interventions tested
– exercise as a single
intervention (59 trials)
– Multi-factorial
programmes (40 trials)
• Group and home-based exercise
programmes, and home safety
interventions delivered by an
occupational therapist reduce rate of
falls and risk of falling.
• Multi-factorial assessment and
intervention programmes reduce rate
of falls but not risk of falling;
• Tai Chi reduces risk of falling.
Gillespie et al. Interventions for preventing falls in older people living in the community.
Cochrane Library 2012
Specialist PSI Exercise Module
Exercise interventions
• Multiple-component group exercise significantly reduced rate of
falls (RaR 0.71; 16 trials) and risk of falling (RR 0.85; 22 trials)
• Multiple-component home-based exercise (RaR 0.68; 7 trials;
and RR 0.78; 6 trials).
• Multiple-component exercise (balance and strength training)
embedded in activities of daily living in people with a history of
falls significantly reduced rate of falls (RaR 0.21; 1 trial) but not risk of
falling.
• Tai Chi, the reduction in rate of falls bordered on statistical significance
(RaR 0.72; 5 trials) but Tai Chi did significantly reduce risk of falling (RR
0.71; 6 trials).
Gillespie et al. Interventions for preventing falls in older people living in the community.
Cochrane Library 2012
Specialist PSI Exercise Module
New Zealand RCTs - OTAGO
Individually tailored programme: Campbell, BMJ 1997
-80+ years, n=233, home-based, physiotherapist
1 year, falls  32%, injuries  39%
Nurse delivered programme at home: Robertson, BMJ 2001
-75+ years, n= 240, home-based, district nurse
-1 year, falls  46%,  serious injuries and hospital costs
Nurse programme at GP centres: Robertson, BMJ 2001
-80+ years, n=450, home-based, general practice nurse
-1 year, falls  30%, injuries  28%
Visually Impaired Older People: Campbell, BMJ 2005
-1 year, home-based. Only effective with full compliance, falls 28%
6 month programme: Liu-Ambrose, JAGS 2008
-70+ years, home-based, cognitive function improvements after 6 months
and after 1 year falls 47%
Specialist PSI Exercise Module
-
FaME – Group & Homebased
• Randomised controlled trial – Exercise
Only
• Women aged 65+, > 3 falls last year
• Exercise-only intervention – 9 months
• Falls decreased by 60%
• Injurious falls decreased by 75%
• Skelton et al. Age Ageing 2005
Co-workers: O.Rutherford and S.Dinan
Specialist PSI Exercise Module
STRENGTH / POWER / ASYMMETRY
Significant isometric and isokinetic improvements in the
exercise group:
• Ankle Plantarflexion
60%
• Ankle Dorsiflexion
40%
• Ankle Inversion
25%
• Ankle Eversion
30%
• Hip Flexion
20%
• Lower Limb Power
25%
• Asymmetry reduced
15%
Specialist PSI Exercise Module
BALANCE & MOBILITY
Mean % change (from baseline) post-training
120
Exercise Group
Control Group
80
40
0
-40
Balance-eyes open
(secs)
Balance-eyes
closed (secs)
Functional Reach Timed Up and Go
(cm)
(sec)
Floor rise (sec)
Specialist PSI Exercise Module
BONE
Significant difference with time and group for L2-L4 spine and Wards
Triangle (F=3.46, p<0.05). Exercisers n=32, Controls n=14.
Time between visit 1 and visit 2 = mean 10.9 (sd 2.7) months
Specialist PSI Exercise Module
FALLS
DURING INTERVENTION
compared to controls (RR 1.19)
•
less likely to have injurious fall (RR 0.51)
DURING FOLLOW UP
•
Exercisers had half the risk of falls
compared to controls (RR 0.53)
•
1.8
1.6
1.4
Exercisers slightly increased risk of falls
Relative Risk
•
1.2
1
0.8
0.6
0.4
0.2
0
Intervention
Follow-up
++ less likely to have injurious falls (RR 0.39)
THREE YEARS FROM BASELINE
•
10% of exercisers had died, were in Hospital /in a nursing home vs 33% of
controls
Specialist PSI Exercise Module
QUALITY OF LIFE
• Improvements in ALL domains of SF36
• Self-reported improvements in
–
–
–
–
–
–
Caring skills
Playing with grandchildren
Bathing instead of showering
Using public transport again
Reduced anxiety and fear
Confidence
• Fallen Angels Club
– Meet every two months in Starbucks, Oxford Street, London, UK!
Specialist PSI Exercise Module
MORBIDITY AND MORTALITY
80% of over 80’s would rather be dead than suffer the
loss of independence that moving to a nursing home
would bring (Salkeld, 2000).
• It’s NEVER TOO LATE
(Fiatarone, 1990)
Specialist PSI Exercise Module
Can exercise prevent fractures?
• Fractures more common in
sedentary people
• Cochrane Review suggests that
exercise does reduce risk of
fractures (2009 & 2012)
• It is possible to increase BMD in
older people (Welsh 1996; Kohrt 1995;
Verschueren 2004)
• It is possible to increase BMD in
fallers (Skelton 2005; Liu Ambrose 2004)
Specialist PSI Exercise Module
Author,
year
Effect
size (95% CI)
Barnett, 2003
Bunout, 2005
Buchner, 1997
Campbell, 1997
Campbell, 1999
Campbell, 2005
Carter, 2002
Cerny, 1998
Day, 2002
Ebrahim, 1997
Faber, Functional walking, 2006
Faber, Tai Chi, 2006
Green, 2002
Hauer, 2001
Korpelainen, 2006
Latham, 2003
Li, 2005
Lin, 2007
Lord, 1995
Lord, 2003
Liu-Ambrose, Resistance, 2004
Liu-Ambrose, Agility, 2004
Luukinen, 2007
McMurdo, 1997
Madureira, 2007
Means, 2005
Morgan, 2004
Mulrow, 1994
Nowalk, Resist./Endurance, 2001
Nowalk, Tai Chi, 2001
Protas, 2006
Reinsch, 1992
Resnick, 2002
Robertson, 2001
Rubenstein, 2000
Sakamoto, 2006
Schoenfelder, 2000
Schnelle, 2003
Sihvonen, 2004
Skelton, 2005
Steinberg, 2000
Suzuki, 2004
Toulotte, 2003
Voukelatos, 2007
Wolf, Tai Chi, 1996
Wolf, Balance, 1996
Wolf, 2003
Woo, Tai Chi, 2007
Woo, Resistance, 2007
Overall (I-squared = 61.5%, p = 0.000)
0.60 (0.36, 0.99) 1.88
1.22 (0.70, 2.14) 1.67
0.61 (0.40, 0.94) 2.21
0.68 (0.52, 0.89) 3.13
0.87 (0.36, 2.10) 0.88
1.15 (0.82, 1.61) 2.74
0.88 (0.32, 2.41) 0.70
0.87 (0.17, 4.29) 0.31
0.82 (0.70, 0.97) 3.80
1.29 (0.90, 1.83) 2.64
1.32 (1.03, 1.69) 3.31
0.96 (0.76, 1.22) 3.34
1.34 (0.87, 2.07) 2.21
0.75 (0.46, 1.25) 1.89
0.79 (0.59, 1.05) 3.05
1.08 (0.87, 1.35) 3.46
0.45 (0.33, 0.62) 2.87
0.67 (0.32, 1.41) 1.13
0.85 (0.57, 1.27) 2.38
0.78 (0.62, 0.99) 3.38
1.80 (0.67, 4.85) 0.72
1.03 (0.36, 2.98) 0.65
0.93 (0.80, 1.09) 3.85
0.53 (0.28, 0.98) 1.48
0.48 (0.25, 0.93) 1.34
0.41 (0.21, 0.77) 1.40
1.05 (0.66, 1.68) 2.04
1.26 (0.90, 1.76) 2.75
0.96 (0.63, 1.46) 2.27
0.77 (0.46, 1.28) 1.88
0.62 (0.26, 1.48) 0.88
1.24 (0.77, 1.98) 2.04
0.71 (0.04, 11.58)0.11
0.54 (0.32, 0.91) 1.84
0.90 (0.42, 1.91) 1.11
0.82 (0.64, 1.04) 3.34
3.06 (1.61, 5.82) 1.40
0.62 (0.38, 1.00) 1.98
0.38 (0.17, 0.87) 0.98
0.69 (0.50, 0.96) 2.81
0.90 (0.79, 1.03) 3.97
0.35 (0.14, 0.90) 0.80
0.08 (0.00, 1.37) 0.10
0.67 (0.46, 0.97) 2.56
0.51 (0.36, 0.72) 2.67
0.98 (0.71, 1.34) 2.86
0.75 (0.52, 1.08) 2.58
0.49 (0.24, 0.99) 1.22
0.78 (0.41, 1.48) 1.41
0.83 (0.75, 0.91) 100.00
.25 .5 1
Favours exercise
2
%
Weight
Systematic
Review of
Exercise
and Falls
But would you
want to be in
these
sessions?
17%
reduction
in falls
Sherrington et al.,
2008 and 2011
4
Favours control
Specialist PSI Exercise Module
What makes the difference?
• Greatest effects of exercise on fall rates
from interventions including:
– Highly challenging balance training
– High dose (50+ hours)
– No walking programme
Sherrington et al., JAGS 2008, NSWPHB 2011
Specialist PSI Exercise Module
Conclusion of 2011 Systematic
Review – Best Practice
Recommendations:
• Exercise must provide a moderate/high challenge to balance
• Sufficient exercise dose (50 hours)
• Ongoing exercise
• Target general community as well as those at high risk
• Brisk Walking should not be prescribed to high risk individuals
• Strength training may be included in addition to balance
Sherrington et al., 2011
Specialist PSI Exercise Module
WHAT’S THE DIFFERENCE?
Gardening
• Physical Activity
– any bodily movement produced by
skeletal muscles that results in
energy expenditure.
DIY
Housework
Bowling
• Exercise
– planned, structured and repetitive
bodily movement undertaken to
improve or maintain one or more
components of physical fitness.
Bouchard 1990
Walking
Cycling
Exercise
class
Sports
Specialist PSI Exercise Module
THE BENEFITS OF EXERCISE
Prevention of :
disease
Coronary Heart Disease, Osteoporosis, Obesity,
Stroke, Depression, Type 2 Diabetes,
Hypertension, Some Cancers
disability
Arthritis, Intermittent claudication, Angina,
Sleep, Low back pain
complications of Constipation, Deep vein thrombosis,
immobility
Oedema, Pressure sores
isolation
Socialisation, Self-efficacy, Confidence
dependence
Functional ability, Falls, Autonomy, Dignity,
Caring skills
Specialist PSI Exercise Module
BENEFITS OF REGULAR PHYSICAL
ACTIVITY
IMPROVES OR MAINTAINS
•
•
•
•
•
Good posture & body image
Intake of nutrients and immunity to infection
Cerebral function, mood, memory
Sleep pattern and duration
Social contacts
INDEPENDENCE
AND QUALITY
OF LIFE
REDUCES OR PREVENTS
•
•
•
•
Falls risk and fear of falling
Breathlessness, fatigue
Incontinence, urinary urgency
Anxiety, Depression, Stress
DEPENDENCE
AND ISOLATION
Specialist PSI Exercise Module
New CMO Guidelines for Older adults
(Start Active, Stay Active 2011)
• Older adults should aim to be active daily. Over
a week, activity should add up to at least 150
minutes of moderate intensity activity in bouts of
10 minutes or more.
• Older adults should also undertake physical
activity to improve muscle strength on at least
two days a week.
• Older adults at risk of falls should incorporate
physical activity to improve balance and coordination on at least two days a week.
• All older adults should minimise the amount of
time spent being sedentary (sitting) for
extended periods.
28
Specialist PSI Exercise Module
A VISCIOUS CYCLE OF INACTIVITY
Physical
deterioration
-
Heart disease
High blood pressure
Aches and pains
Osteoporosis
Further
decrease in
physical activity
Social /
psychological
ageing
-
Feeling ‘old’
‘Acting’ one’s age
Increased stress
Anxiety, depression
Low self-esteem
Increasing
age
Less
exercise
Decreased
physical abilities
- Increased body fat
- Sagging muscles
- Decreased energy
Specialist PSI Exercise Module
UK’S SEDENTARY WAYS
• 40% of people aged 50 or over in the UK are sedentary
• 60-85% are sedentary in ethnic minority groups
 Half of the sedentary over 50’s and
2/3 of over 70’s believe they take
part in enough physical activity to
keep fit.
Specialist PSI Exercise Module
Inactivity related disease?
• Disuse rather than disease?
• 1 wk bed rest  strength by ~ 20%
• 1 wk bed rest  spine BMD by ~1%
• Nursing home residents spend 80-90%
of their time seated or lying down
- leading to ‘Inactivity related
disability’
Specialist PSI Exercise Module
Walk with me !
• Walk from Home - Keighley
Mary Moffat - 93
– Referred by physio after a fall
– Loss of confidence and fear of
falling
– Isolated and lonely and
dependent upon others to get
out
Specialist PSI Exercise Module
BUT not all physical activity is
safe for fallers!
• RCT Increasing physical activity in people with previous upper arm
fracture (Ebrahim 1997)
• Intervention: Brisk walking
• Control: exercise of upper arm
• Falls risk ↑ (Brisk walking > control)
• Fracture risk ↑ (Brisk walking > control)
NICE 2004 &
Sherrington 2011
do not
recommend brisk
walking!
• Beware unsafe pavements!
• PA / Exercise has a complicated relationship with falls – more activity
increases exposure to risk….
Specialist PSI Exercise Module
Physical Activity vs Falls
• Brisk walking correlates with better postural stability in
postmenopausal women (Brooke-Wavell 1998).
– Yet a brisk walking intervention in fallers caused an increased incidence
of falls and fractures (Ebrahim 1997)
• Most falls occur at periods of maximal activity
(Luukinen 1994)
– Yet, Hip fractures are less common in active people (Gregg 1998)
• U-shaped relationship in amount of physical activity and number of
falls (Gregg 1998)
• Community dwelling frequent fallers are less habitually active than
non-fallers (Skelton 2002)
Specialist PSI Exercise Module
Unsupported forward flexion may be risky for
those with previous spinal fractures…….
Type of Exercise
Reoccurrence
of Fracture
• Back extension
16%
• Flexion (abd. curls)
89%
• Combined
53%
• No exercise
67%
Sinaki & Mickelson 1982
Specialist PSI Exercise Module
Patients in Hospital
• Tai Chi + reaching + stepping +
transferring chair to chair
• 1 physiotherapist to max 4 patients,
3 x p/w, 45 mins.
• 173 patients, 82 yrs, sub-acute
ward
• Halved the number of falls
(participant days in hospital)
Haines et al. Clin Rehab 2007
Specialist PSI Exercise Module
Exercise alone? In high risk
7% reduction in fall rate in residential care settings
but this was not statistically significant (p=0.446)
Sherrington et al, 2011
BUT interventions which
provided a challenge to
balance, a high dose of
exercise and no walking
were close to significant
SO….same
recommendations apply
Specialist PSI Exercise Module
Part of a multi-factorial
intervention…care homes
Reduces falls - Becker et al. JAGS 2003
Improves mobility - Jensen et al. Aging Clin Exp Res 2004
Reduces falls risk factors - Dyer et al. Age Ageing 2004
Works better in those with cognitive impairment!!! – Rapp et al. 2008
Specialist PSI Exercise Module
Population Approaches including
increasing physical activity
Do they work?
• Significant decreases or downward trends in fall-related
injuries reported in five large studies
• Relative reduction in fall-related injuries 6 to 33%
• All Interventions included
– Education, advice, medication use, footwear, home hazard
reduction, promotion of physical activity
• Some included
– public lighting, public roadways, housing planning
McClure et al. 2005 Systematic Review
Specialist PSI Exercise Module
Comparison to NICE guidance
100
90
80
70
60
NICE
Assessment
Intervention
Direct
50
40
30
20
81% run
strength and
balance
training
classes BUT
Average
duration 8
weeks and
frequency
once per
week!
10
0
Bone Health
Vision
Gait & Balance
Lamb et al, SDO
report, 2007
Specialist PSI Exercise Module
Royal College of Physicians Report
March 2012
• Audit on NHS exercise provision in falls services across the UK
• First, the good news!
– Over 1,700 older people - 96% felt the exercises were beneficial/quite
beneficial, and 95% were satisfied/very satisfied with their exercise
programme
• Now, the not so good news!
– 86% low frequency (once per week)
– 29% of patients used ankle weights for resistance training
– 52% of patients - exercise programme had been progressed
– 81% of patients - classes had lasted 12 weeks or less
– 73% of patients - home programme lasted for 3 months or less
– Only 54% of sites had PSI trained staff and 41% of sites had
Otago trained staff
Specialist PSI Exercise Module
“Man does not cease to play because he grows old.
Man grows old because he ceases to play”
George Bernard Shaw
If I’d known I was going to live this long, I’d have
taken better care of myself
Dubey Blake
Specialist PSI Exercise Module