Reducing falls in elderly people: A review of exercise interventions

Annette Piotrowski Brown

INTRODUCTION

In Australia, as well as many other countries, falls among elderly people are the leading cause of hip fracture and injury-related death and hospitalisa- tion in people aged 75 years and older ( Fildes, 1993; Lord, 1990; Myers, Young, & Langlois, 1996) . The cost of fall related trauma in Australia is estimated to exceed $A3 billion annually ( Fildes, 1993) . There are also significant non-financial costs to individuals, their carers, families, and com- munities that are impossible to measure.

Falls are more often, however, associated with the devastating and longer-term impacts of restricted activity, persisting disability, and vulner- ability to loss of independence ( Kellog, 1987) . Approximately one third of those who experience a fall express fear of further falls, regardless of the

seriousness of the initial fall outcome ( Tinetti, Mendes de Leon, Doucette, & Baker, 1994) . An additional one third of elderly people who have not previously fallen also report fear related to future falls ( Tinetti, Speechley, & Ginter, 1988) . Fear has a strong relationship with activity restric- tion, marginally affects activities of daily living ( personal and instrumental) , but has no effect on higher levels of physical or social functioning ( Tinetti et al., 1994) .

Several large prospective studies have identi- fied risk factors for falls in the elderly commu- nity-living population ( Graafmans et al., 1996; Lord & Clark, 1996; Nevitt, Cummings, Kidd, & Black, 1989; O’ Laughlin, Robitaille, Boivin, & Suissa, 1993; Tinetti et al., 1988) . These studies have confirmed the complex interplay between falls, impairment resulting from disease, inactivity, and the aging process. Table 1 summarises the spe- cific risk factors for an initial fall identified by these studies. Further research has identified risk factors for recurrent falls and these are summarised in Table 2. It should be noted, however, that while these researchers have evaluated different factors,

A. Piotrow ski Brow n, School of Physiotherapy, Curtin University, Selby Street, Shenton Park 6008, Western Australia. Tel: + 61 8 9266 3650, Fax: + 62 8 9266 3636. email: a.brown@info.curtin.edu.au

Accepted for publication January 1999

Ph ysioth erap y Th eor y a n d Pr a ctice ( 1999) 15, 59–68 © 1999 Psychology Press

Falling by elderly people constitutes a serious issue with potential consequences of injury, disability, and challenges to independence. Interventions aimed at reducing falls by improving physical abilities are widely reported. Current evidence suggests that intervention programmes matched to the elderly individual’ s risk profile, including exercise for strength, balance, and gait problems, can result in significant fall reduction. This article selectively reviews the literature reporting exercise strategies to reduce falls by elderly people. Beneficial programme components and issues relevant to the clinical application of these findings are highlighted.

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the underlying changes resulting in increased fall risk are related to neurological, musculoskeletal, and cognitive impairment. Therefore, there is no one set of universally accepted risk factors for falls ( Oakley et al., 1996) due to the complexity of the problem and the many ways of identifying system- atic changes by clinical and performance-based assessment ( Tinetti, 1986) .

The association between falls and frailty, so often observed clinically, is complex and is not fully understood. Tinetti and Williams ( 1998) reported evidence for the strong association of falls and resultant injuries as precursors of func- tional decline in a community-livin g elderly popu- lation. Falls resulting in injury were associated with deterioration in physical abilities. Recurrent falls were associated with deterioration in both physical and social functioning. Frailty may be preceded by falls which occur as balance, strength, and gait impairments develop. Frailty results from greater losses of physical abilities, as well as many other fac- tors, and is likely to be exacerbated by low levels of confidence in the performance of activities essen- tial to continued independence ( Vellas, Wayne, Garry, & Baumgertner, 1998) . A start has been made to define the process by which fear of falling is associated with decreased activity, poor balance, restricted mobility, and the onset of frailty ( Simpson, Worsfold, Fisher, & Hastie, 1997) . It is an important research objective.

EXERCISE INTERVENTIONS

The prevention of falls is a vital strategy for mini- mising disability ( physical and psycho logical) , pre- venting injury, and impeding the development of frailty and subsequent erosion in quality of life for older people ( Tinetti, 1994) . Review of the litera- ture reveals a substantial body of work reporting the epidemiology of falls and the associated out- comes. Over the past decade increasing attention has been paid to the issue of falls within the com- munity-living elderly population. Reports of programmes aimed at reducing falls and decreas- ing the seriousness of associated outcomes for this population have been published. Initially, strate- gies addressing single and multiple risk factors,

based on the hypothesis that reducing risk factors would reduce the occurrence of falls, were exam- ined. Intervention strategies focused on a single risk factor, for example home hazard modifica- tion, have not been effective in reducing falls ( Sattin et al., 1998; Thompson, 1996) . Strategies addressing multiple risk factors are appropriate as many of the single risk factors cannot be elimi- nated ( Tinetti et al., 1994) . Chronic disease and age-related physiological changes can be managed effectively, but rarely ameliorated. The conse- quences of inactivity often respond to therapeutic intervention. Thus, optimal health management corresponds to multiple risk factor abatement strategies in elderly people at risk of falling.

Two systematic reviews have examined the evi- dence for fall prevention programmes. In 1996, a review of published randomised controlled trials ( RCTs) evaluating fall prevention strategies was conducted ( Sowden et al., 1996) . To be included in this review, RCTs must have evaluated the effec- tiveness of interventions designed to prevent falls in elderly people and reported fall-related out- comes ( occurrence, related injuries, or risk fac- tors) . Following a systematic review of the literature, 36 trials were identified. Prevention strategies evaluated included exercise ( 23) , home assessment ( 9) , footwear ( 1) , programmes in insti- tutional settings ( 3) , nutritional strategies aimed to reduce injury severity ( 1) , and hip protector gar- ments ( 1) . The review concluded that there was inadequate evidence to support any individual intervention but suggested that “balancing, low impact aerobic, or muscle strengthening exercise for older people may reduce the rate of falls”. The review also concluded that home visiting and home hazard modification may be useful in reduc- ing fall risk. Fin ally, the review recommended fur- ther research in several areas, including confirmation of optimal exercise programme parameters for elderly people at risk of falling.

A further systematic review of RCTs with the aim of identifying evidence for programmes to reduce falls in elderly people was published by the Cochrane Collaboration ( Gillespie et al., 1997) . Eighteen RCTs and one meta-analysis were included in the final review. In broad terms, the reported interventions were divided into two groups—evaluation of exercise alone or multiple

PHYSIOTHERAPY THEORY AND PRACTICE 61

interventions targeting specific risk factors identi- fied by individual screening. The review found no significant evidence of fall prevention for programmes consisting of exercise alone or behav- ioural approaches to minimising environmental hazards. The recommended programme for fall prevention in elderly people involved initial health screening for intrinsic and extrinsic factors and was followed by multiple targeted interven- tion strategies for those individuals at risk. Again, this review concluded there was a need for further well-planned research.

Both systematic reviews support fall prevention programmes including an exercise com ponent. In order to provide appropriate exercise pro- grammes for community-living elderly people at risk of falls, examination of successful exercise programmes is essential. Physiotherapists are key providers of exercise interventions for elderly people and knowledge of beneficial programme components is essential for the design of appropri- ate exercise programmes for those considered at risk of falling.

A number of studies have evaluated the effect of exercise focused on improving muscle strength, balance, and gait in healthy elderly and at risk elderly groups. Several approaches have been reported—general exercise programmes for elderly people and specific exercise interventions ( individualised assessment followed by individual or group-based appropriate interventions) designed to decrease fall risk. The majority of programmes specifically include a balance compo- nent. Many of these studies have included moni- toring falls over an extended period of time following intervention to ascertain the effect of intervention on fall frequency. Without extended monitoring, it is impossible to verify programme effects on fall incidence, even when physical abili- ties improve significantly as a result of exercise intervention.

The effects of general exercise programmes designed to be appropriate for community living elderly people have been reported by a small number of authors. Whilst significant improve- ments in balance, strength, flexibility, and/or endurance were observed, no significant changes in fall frequency or outcome have been demon- strated. Lord and colleagues conducted a

randomised controlled trial of 197 community-living elderly women aged 60 years and older ( Lord, Ward, Williams, & Strudwick, 1995) . Intervention subjects completed a 12-month exercise programme of balance and strength activities. While subjects how exercised demonstrated improved measures of sensori- motor function, there was no statistical difference in fall incidence between exercise and control sub- jects. A low to moderate intensity exercise pro- gramme was designed to improve balance and mobility and to prevent or reduce falls in a community-living veteran population ( Means, Rodell, O’ Sullivan, & Cranford, 1996) . After 6 weeks of intervention, there was no effect on falls. General exercise appears to lack specificity for fall prevention in elderly people.

A random ised controlled trial of home-based exercise for women aged 80 years and older offered subjects an individually designed exercise programme designed for each subject by a physio- therapist ( Campbell et al., 1997) . This trial was published after the two systematic reviews described earlier had appeared, hence it was not included in either of them. The initial physical assessment consisted of functional reach, altered base of support in standing, muscle strength, repeated chair stand, timed walk, and timed step tests. Assessment results were used to design an individual programme for each participant. Four initial home visits by a physiotherapist were used to teach the programme of resisted lower limb exer- cise, standing and walking balance activities, func- tional activities, and join t movement exercised. Subjects continued to exercise on their own for the following 6 months and were asked to complete the programme at least three times a week. Sub- jects were able to contact the physiotherapist by telephone at any time and completed monthly reports of falls. Falls were monitored for a 12-month period. The mean rate of falls per year was lower in the exercise group than control sub- jects ( 0.87 vs. 1.34; difference 0.47; 95% confi- dence interval {CI} 0.04–0.90) . Further results indicated that the effect of this programme was most marked in subjects who fell frequently. The findings of this study indicate that an appropri- ately prescribed programme of exercise, taught initially by a physiotherapist and continued at

62 PHYSIOTHERAPY THEORY AND PRACTICE

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home by elderly subjects, can reduce fall inci- dence. This type of programme is attractive because of its apparent economic feasibility.

The provision of specific exercise programmes aiming to increase muscle strength and improve balance and gait as intervention strategies has demonstrated significant impacts on longer-term fall prevalence in other studies. The FICSIT ( Frailtyand Injuries: Cooperative Studies on Inter- vention Techniques) trials were eight collabora- tive independent randomised trials, conducted at several centres within the USA which aimed to decrease falls and frailty in elderly subjects ( Province et al., 1995) . Five trials examined the effect of short-term exercise programmes varying in frequency, intensity, duration, and mode on community-livin g elderly subjects. Additionally, interventions which focused on the abatement of other fall risk factors were provided. Two further trials were conducted in nursing homes and evalu- ated the effect of strength training and nutritional supplementation ( Fiatarone et al., 1994) and indi- vidualised physical therapy programmes involving resistance, flexibility, balance, and functional training ( Mulrow et al., 1994) . The final project evaluated hip protector garments in reducing hip fracture incidence ( Wallace et al., 1993) .

The five individual trials involving commu- nity-living elderly subjects evaluated the effect of exercise ( consisting of combinations of balance, strength, endurance, join t movement, and flexibil- ity training) , behavioural and education pro- grammes, targeted risk abatement programmes based on individual assessment, medication review, and specific balance training programmes ( Buchner et al., 1997; Hornbrook et al., 1994; Tinetti et al., 1994; Wolf, Barnhart, Ellison, & Coolger, 1996; Wolfson et al., 1996) . Specific details of the programme components are summa- rised in Table 3. Monitoring of falls continued for periods ranging from 2 to 4 years.

Two individual FICSIT trials demonstrated sig- nificant reductions in fall risk. A total of 301 sub- jects participated in a randomised controlled trial designed to evaluated the effectiveness of a multi- ple risk factor reduction strategy ( Tinetti et al., 1994) . The trial involved a 3-month targeted risk abatement programme for intervention subjects based on individual assessment results. The

programmes consisted of home-based exercise ( strength, balance, join t movem ent) , medication review, and behavioural and education programmes. The relative change in risk of falling, after adjusting for other factors, indicated signifi- cantly lower risk following completion of the programme and over the following year ( falls inci- dence ratio 0.69, 95% CI: 0.52–0.90) . In addition, the authors reported that a significantly longer time to first fall was recorded among intervention subjects. Thus, the multiple risk factor abatement strategy demonstrated a significant reduction in the risk of falls. Given the complex nature of fall- ing associated with advanced age, Tinetti and col- leagues ( 1994) demonstrated an effective and appropriate intervention programme to reduce fall risk. These programmes require multiple and complex interventions, individual assessment, and treatment provision. However, evidence of the cost-effectiveness of this study, particularly for individuals at high risk of falling, has been demon- strated ( Rizzo, Baker, McAvay, & Tinetti, 1996) .

A further trial by Wolf and colleagues ( 1996) reported the results of a randomised controlled trial, evaluating differing methods of balance training and involving 200 community-living elderly subjects. Specific balance training utilised either a computerised balance platform to provide centre of mass feedback or Tai Chi Quan ( Chinese martial art) classes twice a week over a 15-week period. Participation in the Tai Chi Quan inter- vention was associated with a significant reduction in the risk of multiple falls by 47.5% when com- pared to control subjects over the 4-month fol- low-up period. The Tai Chi Quan intervention also significantly reduced reported fear of falling. How- ever, Tai Chi Quan participants did not demon- strate improvement of postural stability measures ( Wolf et al., 1997) . These researchers concluded that Tai Chi Quan appeared to affect confidence rather than postural sway. Tai Chi Quan is a modal- ity requiring further evaluation for suitability as an intervention for elderly people at risk of falling.

Other studies within the FICSIT group did not individually demonstrate significant fall reduc- tion. Both Hornbrook and colleagues ( 1994) and Buchner and colleagues ( 1997) failed to influence fall measures during individual trials. The effect of exercise ( consisting of balance, strength, and

64 PHYSIOTHERAPY THEORY AND PRACTICE

endurance training) , behavioural and education programmes over a 4-month period did not dem- onstrate fall reduction in 1323 community-living elderly subjects, ( Hornbrook et al., 1994) . Results reported by Buchner et al. ( 1997) following a 6 month long trial of flexibility, resistance, and endurance training indicated that mildly impaired community-living elderly subjects may not benefit as a result of short-term exercise programmes.

Wolfson and colleagues evaluated the effect of a 3-month programme of balance training, strength training, and combined balance and strength training in a randomised controlled trial involving 110 healthy community-dwelling elderly subjects ( Wolfson et al., 1996) . The intervention programmes were followed by a 6-month main- tenance programme of weekly Tai Chi Quan sessions. Significant gains in balance and strength were noted post-intervention. There was no inter- action between balance and strength improve- ments. After 6 months of the Tai Chi Quan maintenance programme these significant bal- ance and strength gains were maintained. This study provides valuable information about the maintenance of intervention gains. Cost-effective intervention strategies, designed to maintain phys- ical improvements, are vital to ensure the ongoing benefits in fall reduction for elderly people.

Meta-analysis of the results of seven FICSIT trials ( excluding Wallace et al., 1993) provided an opportunity to evaluate the effect of exercise for a much larger sample of subjects than offered by individual trials ( Province et al., 1995) . Results demonstrated significant evidence for interven- tions including an exercise component as effective in reducing falls. After adjusting for other covariates, the relative change in risk of falling was approximately 10% lower ( falls incidence ratio 0.90, 95% CI: 0.81–0.99) . Programmes that specifi- cally targeted balance resulted in a further reduc- tion in adjusted risk with a falls incidence ratio of 0.83 ( 95% CI: 0.70–0.98) . No effect was noted for injurious falls. Whilst individual trials within the group offered varying strategies, results of the meta-analysis present evidence that FICSIT exer- cise interventions, especially those including spe- cific balance programmes, reduced the risk of falls for elderly subjects. No analysis of exercise dura- tion was reported.

Other studies examining the effect of exercise on falls have reported varying efficacy. A trial of weightbearing exercise aiming to improve bone density in elderly women demonstrated differ- ences in falls incidence between exercise and control groups for only a 6-month subsection of the 2-year monitoring period ( McMurdo, Mole, & Paterson, 1997) . Overall, however, there was no significant difference in fall rates between the two groups. A multidimensional exercise programme measured effectiveness in areas of balance, mobility, and fall risk for older adults ( Shumway- Cook, Gruber, Baldwin, & Liao, 1977) . Improved balance and mobility performance translated into decreased fall risk for exercise subjects. However, this study’ s usefulness is limited as it did not report on actual falls following the exercise programme.

Several research design issues must be consid- ered when evaluating programmes to reduce falls. Exercise programmes for elderly populations must be of sufficie nt duration and intensity to facilitate physiological change. Appropriateness for each individual must be considered. Studies need to be designed to follow-up participants over a lengthy period of time ( i.e. years rather than months) in order to show effectiveness in reducing falls. Additionally, appropriate levels of statistical power often rely on large subjects numbers making clinical trials a substantial undertaking.

Research in progress at Curtin University in Western Australia has evaluated exercise inter- ventions to reduce frailty in community-living elderly people. A randomised controlled trial of 108 elderly subjects demonstrated immediate and longer-term reduction in falls following a 16-week exercise and functional retraining programme including balance, strength, and gait components ( Piotrowski, Cole, & Allison, 1997) . Significantly improved balance and functional abilities were evident for exercise participants when compared to control subjects immediately following the com- pletion of intervention. These differences were still evident 6 months post-intervention and sug- gest that intervention gains may be translated into and maintained by enhanced functional ability over the longer term. Control subjects experi- enced more falls than intervention subjects during the first 6 months after completion of the

PHYSIOTHERAPY THEORY AND PRACTICE 65

programme. Further analyses of the results of this research are in progress.

The translation of effective research protocols into clinical practice is challenging. Exercise has many well-documented physical and psychological benefits for older people, especially those with low activity levels ( Hillsdon, Thorogood, Antiss, & Morris, 1995) and is likely to be cost-effective when appropriately prescribed ( Nicholl, Coleman, & Brazier, 1994) . However, benefits are not fully real- ised unless regular exercise continues over a number of months ( Buchner et al., 1997) . Adher- ence to exercise programmes by elderly people is an important issue, often overlooked in the re- search setting, where many subjects are volunteers and eager to participate. Dropout rates for exer- cise have been reported as high as 50% ( Dishm an, 1988) and appear to be higher for subjects with lower levels of physical ability ( Williams & Lord, 1995) . Among elderly adults, this figure may well be higher due to illness ( Kriska et al., 1986) , isola- tion, depression, and transportation difficulties ( Brown, 1998) . Most of the studies involving exer- cise interventions discussed in this paper reported dropout rates of 30% or less. Initiation of exercise by older women is strongly associated with the bar- riers perceived by the individual ( Lee, 1993) . Clinically, careful planning prior to programme commencement must address specific physical and psychosocial strategies to increase adherence ( Brown, 1998) . Enjoyable, convenient exercise, offering social support and contact or interaction with a health professional appears to be most useful. These variables have been reported as sig- nificant in maintaining adherence ( Hillsdon, Thorogood, Anstiss, & Morris, 1995) .

Exercise duration and intensity is a vital consid- eration when prescribing intervention for elderly subjects. Programmes aimed at reducing falls should be based on appropriate levels of intensity and duration to effect changes in balance and muscle strength. Additionally, exercise pro- grammes must be dynamic and responsive to indi- vidual physical improvement. Specific attention to ways of improving confidence and reducing fear of falling are vital in the planning of such a pro- gramme. Fin ally, maintenance of physical gains as a result of exercise must be considered and appro- priate activities recommended to elderly people.

CONCLUSION

Exercise intervention, including home-based programmes, has demonstrated efficacy in fall reduction in elderly people, especially when a bal- ance component is included. Individual assess- ment of risk factors as part of a targeted multidimensional programme has also resulted in significant declines in fall risk. The duration of effective exercise programmes has ranged from 3 to 6 months. Maintenance of intervention gains appears possible with continued activity. Tai Chi Quan has demonstrated pleasing results as both an intervention and a maintenance activity and requires further evaluation. Specific intervention strategies, including exercise, to address multiple risk factors offer the best protection against falls in later life.

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