Exercise for Falls Prevention: Decision-making among Australian-born and Italian-born Older People

ABSTRACT

In this article, we examine factors contributing to decision-making in regards to participation and adherence to exercise to reduce falls by older people with recent falls history. Nineteen participants (9 Australian-born and 10 Italian-born; median age 78 years) who had ≥1 fall in the past 12 months and completed a community based physiotherapy program were recruited. Semi-structured interviews were conducted, transcribed, and thematically analyzed. The findings show that family, client-clinician relationship and personal experience affected decision-making and exercise participation. The findings revealed that a number of factors influenced older people’s decision and uptake of falls prevention exercise, including personal goals, recommendations from health care providers, and life experiences. There were some differences between the Italian-born and the Australian-born participants, including that most Australian-born participants adhere to exercise programs in order to avoid requiring nursing home care, whereas Italian-born individuals did not wish to be dependent on their children. An understanding of personal motivating and de-motivating factors for exercise for falls prevention are important for health and social care professionals to consider in engaging some groups of older people.     

Effective Exercise for the Prevention of Falls: A Systematic Review and Meta‐Analysis

OBJECTIVES: To determine the effects of exercise on falls prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with larger reductions in falls. DESIGN: Systematic review with meta‐analysis. Randomized controlled trials that compared fall rates in older people who undertook exercise programs with fall rates in those who did not exercise were included. SETTING: Older people. PARTICIPANTS: General community and residential care. MEASUREMENTS: Fall rates. RESULTS: The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants, rate ratio (RR)=0.83, 95% confidence interval (CI)=0.75–0.91, P<.001, I²=62%). The greatest relative effects of exercise on fall rates (RR=0.58, 95% CI=0.48–0.69, 68% of between‐study variability explained) were seen in programs that included a combination of a higher total dose of exercise (>50 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program. CONCLUSION: Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention.     

Measuring accumulated health-related benefits of exercise participation for older adults: the Vitality Plus Scale.

BACKGROUND: Existing measures fail to capture the perceived benefits attributed to exercise participation by older adults themselves. Noticeable improvements in sleep, energy level, bodily aches and pains, constipation, and other psychophysical aspects of "feeling good" may represent ongoing sources of motivation for continued participation. The Vitality Plus Scale (VPS) was developed to measure these potential health-related benefits of exercising. METHODS: The 10-item VPS was developed using an inductive approach, in collaboration with regularly exercising older adults and their instructors. Multiple samples of exercises and nonexercisers ranging in age from 40 to 94 were used to examine the reliability and validity of the new scale. RESULTS: The VPS showed good internal consistency and test-retest reliability over one week. Scores were able to discriminate on the basis of various indicators of health status and self-reported level of physical activity, and were related to two measures of functional mobility. Convergence was found with several subscales of the SF-36, whereas low correlations emerged with a measure of episode-specific sensations. Responsiveness to change was found with various types of exercise for individuals with low to moderate scores prior to participation. CONCLUSIONS: Improvements in sleep, energy level, mood, and generally feeling good appear to be the most noticeable benefits of exercising for many adults. These associations are reinforced by sustained exercise participation. Capturing these interrelated psychophysical constructs in a single, short measure will enable exercise researchers and instructors to measure incremental improvements previously reported only anecdotally.     

Perceptions of older people about falls injury prevention and physical activity

Objectives: The purpose of this study was to explore the beliefs and perceptions of older people about falls injury prevention services, and to identify incentives and barriers to attending falls prevention services, including programs targeting physical activity. Methods: Seventy‐five people over age 60 years who were members of community groups completed a 23‐item survey that was returned by mail. Survey items included self‐reported falls and confidence when walking, awareness of falls prevention strategies, desirable programs for a falls prevention service, and incentives and barriers to participation in physical activity programs. Results: Twenty‐eight per cent of respondents had fallen within the previous 6 months, yet just over half (54%) were aware there were strategies to prevent falling, despite the majority of the sample being physically active (81%) and at least reasonably confident about walking (84%). The features that were considered most desirable for a falls prevention service were group exercise programs (61%), educational talks about health issues (57%), and vision/eye glasses assessment (52%). The most commonly reported incentives for attending a physical activity group included having a doctor advise them to attend (61%) or having a friend who attended the group (55%), and the most common barrier to attending a physical activity group was transportation (43%). Conclusions: Despite consistent numbers of older people experiencing falls, there is little awareness among older people that strategies exist to prevent falling. It appears that motivating older people to participate in physical activity with the aim of falls prevention will largely depend on the encouragement of their doctor or their peers.     

Old women with a recent fall history show improved muscle strength and function sustained for six months after finishing training

BACKGROUND AND AIMS: Restricted physical activity as a consequence of chronic disease or injury is a predictor of functional decline. The aim of this study was to test the hypothesis that a 6- month multidimensional training program would have sustained beneficial effects upon the physiological, functional and psychological condition of old women with a recent history of falls. METHODS: Participants were 65 home-dwelling women (70-90 years) identified from hospital records as having had an accidental fall. After assessment of muscle strength, balance performance, walking speed, balance confidence, and physical activity level, the participants were randomly assigned to a control group (n=33) or a training group (n=32), who performed a multidimensional training program including moderate resistance exercise and balance exercise twice weekly for 6 months. Measurements were repeated after 6 and 12 months. RESULTS: Six months of multidimensional training resulted in significant improvements and between-group differences in isometric knee extension strength (p<0.05), trunk extension/ flexion strength (p<0.001), habitual/maximal walking speed (p<0.001) and balance performance (p<0.001). At follow-up, 6 months after intervention, these improvements were preserved in the training group and there was also a significant between- group difference with regard to balance confidence. No between-group differences were found concerning number of falls or physical activity level during the one-year study period. CONCLUSIONS: A multi-dimensional training program produced significant improvements in physiological and functional risk factors for falls and disability in women aged 70-90 years with a recent history of falls.     

Does improved functional performance help to reduce urinary incontinence in institutionalized older women? a multicenter randomized clinical trial

ABSTRACT: BACKGROUND: Urinary incontinence (UI) is a major problem in older women. Management is usually restricted to dealing with the consequences instead of treating underlying causes such as bladder dysfunction or reduced mobility.The aim of this multicenter randomized controlled trial was to compare a group-based behavioral exercise program to prevent or reduce UI, with usual care. The exercise program aimed to improve functional performance of pelvic floor muscle (PFM), bladder and physical performance of women living in homes for the elderly. METHODS: Twenty participating Dutch homes were matched and randomized into intervention or control homes using a random number generator. Homes recruited 6--10 older women, with or without UI, with sufficient cognitive and physical function to participate in the program comprising behavioral aspects of continence and physical exercises to improve PFM, bladder and physical performance. The program consisted of a weekly group training session and homework exercises and ran for 6 months during which time the control group participants received care as usual. Primary outcome measures after 6 months were presence or absence of UI, frequency of episodes (measured by participants and caregivers (not blinded) using a 3-day bladder diary) and the Physical Performance Test (blinded). Linear and logistic regression analysis based on the Intention to Treat (ITT) principle using an imputed data set and per protocol analysis including all participants who completed the study and intervention (minimal attendance of 14 sessions). RESULTS: 102 participants were allocated to the program and 90 to care as usual. ITT analysis (n = 85 intervention, n = 70 control) showed improvement of physical performance (intervention +8 %; control -7 %) and no differences on other primary and secondary outcome measures. Per protocol analysis (n = 51 intervention, n = 60 control) showed a reduction of participants with UI (intervention -40 %; control -28 %) and in frequency of episodes (intervention -51 %; control -42 %) in both groups; improvement of physical performance (intervention + 13 %; control -4 %) was related to participation in the exercise program. CONCLUSIONS: This study shows that improving physical performance is feasible in institutionalized older women by exercise. Observed reductions in UI were not related to the intervention. [Current Controlled Trials ISRCTN63368283].     

Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data

OBJECTIVES: Our falls prevention research group has conducted four controlled trials of a home exercise program to prevent falls in older people. The objectives of this meta-analysis of these trials were to estimate the overall effect of the exercise program on the numbers of falls and fall-related injuries and to identify subgroups that would benefit most from the program. DESIGN: We pooled individual-level data from the four trials to investigate the effect of the program in those aged 80 and older, in those with a previous fall, and in men and women. SETTING: Nine cities and towns in New Zealand. PARTICIPANTS: One thousand sixteen community dwelling women and men aged 65 to 97. INTERVENTION: A program of muscle strengthening and balance retraining exercises designed specifically to prevent falls and individually prescribed and delivered at home by trained health professionals. MEASUREMENTS: Main outcomes were number of falls and number of injuries resulting from falls during the trials. RESULTS: The overall effect of the program was to reduce the number of falls and the number of fall-related injuries by 35% (incidence rate ratio (IRR) = 0.65, 95% confidence interval (CI) = 0.57-0.75; and, respectively IRR = 0.65, 95% CI = 0.53-0.81.) In injury prevention, participants aged 80 and older benefited significantly more from the program than those aged 65 to 79. The program was equally effective in reducing fall rates in those with and without a previous fall, but participants reporting a fall in the previous year had a higher fall rate (IRR = 2.34, 95% CI = 1.64-3.34). The program was equally effective in men and women. CONCLUSION: This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall.     

The beneficial effects of group-based exercises on fall risk profile and physical activity persist 1 year postintervention in older women with low bone mass: follow-up after withdrawal of exercise

OBJECTIVES: To determine whether exercise-induced reductions in fall risk are maintained in older women 1 year after the cessation of three types of interventions--resistance training, agility training, and general stretching. DESIGN: One-year observational study. SETTING: Community. PARTICIPANTS: Ninety-eight women aged 75 to 85 with low bone mass. MEASUREMENTS: Primary outcome measure was fall risk, measured using the Physiological Profile Assessment tool. Secondary outcome measures were current physical activity level, assessed using the Physical Activity Scale for the Elderly, and formal exercise participation, assessed using an interview. RESULTS: At the end of the follow-up, the fall risk of former participants of all three exercise programs was maintained (i.e., still reduced) from trial completion. Mean fall risk value at the end of follow-up was 43.3% lower than mean baseline value in former participants of the resistance-training group, 40.1% lower in the agility-training group, and 37.4% lower in the general stretching group. Physical activity levels were also maintained from trial completion. Specifically, there was a 3.8% increase in physical activity from baseline for the resistance-training group, a 29.2% increase for the agility-training group, and a 37.7% increase for the general stretching group. CONCLUSION: After three types of group-based exercise programs, benefits are sustained for at least 12 months without further formal exercise intervention. Thus, these 6-month exercise interventions appeared to act as a catalyst for increasing physical activity with resultant reductions in fall risk profile that were maintained for at least 18 months in older women with low bone mass.     

Development, implementation, and evaluation of an Interprofessional Falls Prevention Program for older adults

This article describes the development and implementation of an Interprofessional Falls Prevention Program (IFPP) designed for community-dwelling seniors. The program was a collaborative pilot research study conducted in a retirement home and an outpatient hospital setting. The pilot was successful and was positioned into a permanent falls prevention program. The IFPP aimed at improving physical function and balance and reducing the fear of falling in seniors with a history of falls. The pilot study included an interprofessional falls assessment followed by a 12-week program of once-weekly group education and exercise sessions, 3- and 6-month follow-up visits, and individual counseling. To measure program effectiveness, the Berg Balance Scale, the Timed Up and Go Test, the Falls Efficacy Scale, and the Morse Fall Risk Scale were used at baseline, upon program completion, and at 3- and 6-month follow-up. Process measures were also collected, including patient satisfaction. Persistent improvements were found in participants' balance, strength, functional mobility, and fear of falling. Patient satisfaction with the program was high. Challenges faced in program implementation are also highlighted.     

Exercise as a Therapeutic Intervention in Patients with Stable Ischemic Heart Disease: An Underfilled Prescription

Treatment for stable ischemic heart disease may include guideline-directed pharmacologic therapy, coronary revascularization, and lifestyle and behavioral changes, including structured exercise. Of these, regular exercise is arguably one of the most cost-effective yet underused interventions. Most patients with stable ischemic heart disease are eligible for secondary prevention programs, which should include exercise training regimens, but participation in such programs remains suboptimal. This review emphasizes the importance of education for both patients and providers to enhance participation in lifestyle physical activity, structured exercise, or both.     

Long-term effects of exercise on psychological functioning in older men and women

The purpose of this study was to determine the psychological, behavioral, and cognitive changes associated with up to 14 months of aerobic exercise training. For the first 4 months of the study, 101 older (greater than 60 years) men and women were randomly assigned to one of three conditions: Aerobic exercise, Yoga, or a Waiting List control group. Before and following the intervention, all subjects completed a comprehensive assessment battery, including measures of mood and cognitive functioning. A semi-crossover design was employed such that, following completion of the second assessment, all subjects completed 4 months of aerobic exercise and underwent a third assessment. Subjects were given the option of participating in 6 additional months of supervised aerobic exercise (14 months total), and all subjects, regardless of their exercise status, completed a fourth assessment. Results indicated that subjects experienced a 10-15% improvement in aerobic capacity. In general, there were relatively few improvements in cognitive performance associated with aerobic exercise, although subjects who maintained their exercise participation for 14 months experienced improvements in some psychiatric symptoms. However, the healthy subjects in this study were functioning at a relatively high level to begin with, and exercise training may produce greater improvements among elderly with concomitant physical or emotional impairments.     

Practices and strategies for the prevention of falls in the osteoporotic elderly

Among seniors with osteoporosis, falls can cause devastating injuries such as hip fractures even with only weak impacts. We have begun a combined medical examination and educational program for exercise to prevent injurious falls. To make fall prevention practices more widespread, we hold one-day simplified fall prevention program and instruction courses for practitioners.     

Statistical analysis of efficacy in falls prevention trials

BACKGROUND: Many different and sometimes inappropriate statistical techniques have been used to analyze the results of randomized controlled trials of falls prevention programs for elderly people. This makes comparison of the efficacy of particular interventions difficult. METHODS: We used raw data from two randomized controlled trials of a home exercise program to compare the number of falls in the exercise and control groups during the trials. We developed two different survival analysis models (Andersen-Gill and marginal Cox regression) and a negative binomial regression model for each trial. These techniques a) allow for the fact that falls are frequent, recurrent events with a non-normal distribution; b) adjust for the follow-up time of individual participants; and c) allow the addition of covariates. RESULTS: In one trial, the three different statistical techniques gave surprisingly similar results for the efficacy of the intervention but, in a second trial, underlying assumptions were violated for the two Cox regression models. Negative binomial regression models were easier to use. CONCLUSION: We recommend negative binomial regression models for evaluating the efficacy of falls prevention programs.     

Physical performance effects of low-intensity exercise among clinically defined high-risk elders

BACKGROUND: Falls are among the leading causes of injuries and deaths. Results from a number of studies have suggested that a community-based exercise program may be effective in improving lower body strength, although some have shown only limited improvements. However, the impact of these programs on gait and balance are equivocal. Further, studies that have specifically targeted deconditioned elderly individuals, rather than individuals drawn from the general community, either showed limited or no improvements in gait and balance. OBJECTIVE: This study examined the effectiveness of a community-based, short-term, low-intensity exercise intervention strategy on measures of mobility skills, gait and balance, and muscle strength for a clinically targeted group of elderly individuals at high risk of falls. METHODS: 245 men and women aged 60 years or older were randomized into either an intervention or control group and received a baseline (T1) assessment. Subjects in the intervention group received up to 24 sessions (45 min long) of low-intensity standard exercise modalities tailored to the individual patient over an 8- to 10-week period. At the conclusion of the program, the participants in the intervention group were instructed to continue performing the exercises at home until 1 year after T1. Measures of physical function and performance were collected for all subjects at three different points of study enrollment. RESULTS: Of the subjects assessed at baseline, 138 (56%) also had a postintervention assessment (T2), 128 (52%) had a 6-month follow-up assessment (T3), and 105 subjects had assessments at all time points. Primary analyses were based on the 105 subjects who had assessments at all time points. Intervention and control subjects did not differ in any of the physical function or performance measures at baseline. Between T1 and T2, the intervention subjects showed significantly greater improvement than the control subjects on all outcomes, with improvements plateauing for most measures between T2 and T3. Gait and balance scores continued to improve throughout the study period for both groups of subjects. CONCLUSIONS: This easily implemented, low-intensity exercise program may lead to improvements in physical functioning that are retained over the long term and effectively targets a clinically defined population of deconditioned elders at high risk of falling and sustaining serious injury.     

Preventing falls and fall-related injuries in hospitals

Falls are a widespread concern in hospitals settings, with whole hospital rates of between 3 and 5 falls per 1000 bed-days representing around a million inpatient falls occurring in the United States each year. Between 1% and 3% of falls in hospitals result in fracture, but even minor injuries can cause distress and delay rehabilitation. Risk factors most consistently found in the inpatient population include a history of falling, muscle weakness, agitation and confusion, urinary incontinence or frequency, sedative medication, and postural hypotension. Based on systematic reviews, recent research, and clinical and ethical considerations, the most appropriate approach to fall prevention in the hospital environment includes multifactorial interventions with multiprofessional input. There is also some evidence that delirium avoidance programs, reducing sedative and hypnotic medication, in-depth patient education, and sustained exercise programs may reduce falls as single interventions. There is no convincing evidence that hip protectors, movement alarms, or low-low beds reduce falls or injury in the hospital setting. International approaches to developing and maintaining a fall prevention program suggest that commitment of management and a range of clinical and support staff is crucial to success.     

Does action follow intention with participation in home and group-based falls prevention exercise programs? An exploratory,prospective, observational study

BackgroundExercise for falls prevention is effective but of limited uptake in real life. The link between intention and behavior is central to many health-behavior models, but has not been examined in the falls prevention exercise context.ObjectiveThis study examines this relationship and prospectively identifies factors associated with participation in group and home-based falls prevention exercise.DesignThis was an observational study of community-dwelling adults in Australia >70 years of age with a 12 month follow-up (n = 394 commenced baseline assessment, n = 247 commenced follow-up).MethodsIntention, and other potential predictive factors examined, were measured at baseline while participation was measured using self-report at 12 month follow-up.ResultsBetween 65% and 72% of our sample at baseline agreed or strongly agreed they would participate in the falls prevention exercise programs. n = 27 respondents participated in home-based exercise during follow-up and had intention to do so while n = 29 who participated did not have intention. In contrast, n = 43 respondents participated in group exercise and had intention to do so compared to 11 who participated but did not intend to at baseline. Perception of personal effectiveness and previous exposure to the exercise intervention were most strongly predictive of future participation.ConclusionMore people who do not want to participate in home exercise actually participate in home exercise than people who do not want to participate in group exercise that actually do. It may be easier to convince people who do not want to participate in falls prevention exercise to participate in a home program.     

The basic idea and exercise program of "fall and fracture prevention school" for elderly people

With the arrival of an aging society in Japan, accidents among elderly people involving falls and bone fractures are on the increase. Efforts to prevent such accidents are strongly required, so the concept of a "fall and fracture prevention school" is spreading. The aims of these classes are to make elderly people aware of the condition of their bodies and to improve deteriorating physical ability through exercise programs, since the latter is the cause of such falls. In conducting an exercise program for the elderly, it is important to make it enjoyable as well as safe.     

Intervention study using a fall prevention program to prevent functional decline of old-old elderly in a rural community

The purpose of this study was to determine the effects of a fall prevention program for old-old elderly in a rural community in Japan. The subjects were 71 inhabitants aged 75 and over who used community health and welfare services such as day services and social activity classes. They were divided into two groups: 34 in the experimental group, and 37 controls. Physical therapists and care staff instructed the experimental group in fall prevention exercises once per two weeks from December 2000 to March 2001. The control group utilized the usual services without any special instructions. All subjects were evaluated by physical performance tests and a self-administered questionnaire before and after 4 months following the intervention. Collected data were analyzed by two-way ANOVA using intervention and time as independent variables, and physical performance tests as dependent variables. Twenty-three of the experimental group and 26 of the control group completed both baseline and follow-up surveys. There were no significant differences in physical ability between the two groups at the time of the baseline survey. The experimental group showed excellent compliance and participated in all sessions during the intervention period. Interaction effects on body mass index and Timed Up and Go Test were shown to be significant (F = 5.623, P < 0.01: F = 6.541, P < 0.05). There were no changes in terms of other physical and psychological factors. Our results showed specific exercises could improve some aspects of physical performance. Since the group exercise program can be effective for old-old elderly, it might contribute to decreasing falls and prolong independent living.