How effective is physical exercise in decreasing the incidence of falls in elderly people without cognitive impairment?

Background and Rationale

            Providing safe and quality care to clients of all ages is an important focus of nursing practice. The population of older individuals is growing rapidly worldwide (Fereira, Israel, & Guimaraes, 2014). Approximately 500 million people globally are 65 year of age and above, and this number is projected to rise to 1 billion by 2030 (Kloubec, Rozga & Block, 2012). Advancing age is associated with physical inactivity as well as degenerative processes in the muscular and central nervous system, which can lead to reduced muscle strength/power performance and impaired balance. These declines contribute to fall occurrence (Kuptniratsaikul et al., 2011; Lacroix et al., 2016). Muscle weakness, gait instability and balance deficits are representative of the most important intrinsic factors for fall risk in the elderly population (Lacroix et al., 2016). Nurses can play a critical role in early detection of these risk factors and the implementation of appropriate preventive strategies (Zhao et al., 2016).

            Falls can lead to fractures and pain, premature hospital or nursing home admission, immobility, reduced quality of life, and even death (El-Khoury, Cassou, Charles, & Dargent-Molina, 2013; Lacroix et al., 2016; Kloubec et al. 2012; Pata, Lord, & Lamb, 2013). Older persons who have experienced a fall tend to develop fear of falling, resulting in anxiety (Song & Kim, 2015). The healthcare costs associated with fall-related injuries are enormous, being about $19 billion, with projections of up to $240 billion by 2040 (Lacroix et al., 2016). The implementation of easy to administer and cost-efficient interventions for fall prevention (Lacroix et al., 2016) has become an integral part of geriatric nursing (Bullo et al., 2015; Kloubec et al., 2012).

             Robust evidence is available to support exercise use in the prevention of falls, with prevention of up to 42 percent of falls being achieved by both home and group-based, well-designed exercise interventions (Gawler et al., 2016; Kloubec et al., 2012).  Regular exercise is believed to reduce fall risk in older people through various mechanisms, including ensuring good flexibility, improving cardiovascular function, and increasing balance (Kuptniratsaikul et al., 2011; Song & Kim, 2015). These studies, however, have included older adults with or without impairments (Mulligan et al., 2014). Additionally, there is the challenge of delivering an exercise intervention that is most effective for older adults (Freiberger et al., 2013).  The purpose of this study is to verify whether physical exercise is effective in reducing fall incidence in older adults without cognitive impairment.

Critical Review

Review Question

            This project focuses on the effectiveness of physical exercise in deceasing fall incidence in elderly people without cognitive impairment. The risk of falls has been shown to increase in inactive people and those with poor balance and strength (Gawler et al., 2016). Available data shows that every one in three individuals aged 65 years and over experiences a fall every year (Martin et al., 2013; Mulligan, Tschoepe, & Smith, 2014).These falls threaten the functionality and independence of older individuals. Fall prevention, therefore, it a vital component strategies to counteract the increasing fall-related burden (Freiberger et al., 2013).

Literature Search Strategy

            Comprehensive literature search to answer the research question was accomplished using various electronic academic databases, including PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Google Scholar. During the search, some keywords were   used to aid in locating publications, including exercise, physical activity, physical exercise, falls, fall incidence, older adults, older people, geriatrics, and the elderly. These keywords were combined to form search statements using the Boolean search strategy to narrow down the search and explore the databases to locate relevant publications. This search strategy contains three operators, including ‘AND’, ‘OR’ and ‘NOT’, which are used to combine the search terms and focus the search. The keywords were combined to yield relevant statements as shown in this example: Exercise OR physical exercise OR physical activity, AND falls OR fall incidence in geriatrics OR older adults OR the elderly, NOT cognitive impairment.

            To ensure a more focused search, the researcher applied inclusion and exclusion criteria. The inclusion criteria included peer-reviewed journal articles, articles published in the English language, publication dates not older than seven years, studies conducted on older adults, and publications that were relevant to the research question. The exclusion criteria entailed studies with publication dates older than 7 years, studies on animal models, studies not published in the English language, clinical practice guidelines, expert opinions, and editorials. The researcher retrieved abstracts of articles that met the inclusion criteria and scanned through them to assess their relevance to the study question. Te full articles were retrieved for analysis (see summary table below). 

Quality Assessment

            All the articles selected for the review are peer reviewed journal articles, implying that the various authors adhered to the editorial standards of the different journals prior to publication. The focus of all the studies was on exercise and falls in older adults, making them relevant for the research question. In addition, the articles contain up-to-date relevant information on the topic on interest, with publication dates from 2012 to 2017. Most of the studies included in this review were of high quality based on their research designs. Majority were randomized controlled trials (RCTs) (Dadgari et al. 2016; Freiberger et al. 2013; Hwang et al. 2016; Lacroix et al., 2016; Pai, Bhatt, Yang and Wang, 2014; Song & Kim, 2015; Yamada et al. 2013; Zhao, Chung, & Tong, 2017; Zhuang et al., 2014). The RCTs involved random allocation of study participants either to intervention or control groups to ensure true comparability and yield accurate, quality results on the effectiveness of the exercise interventions.

            Some of these studies used large and representative sample sizes (Dadgari et al., 2016; Freiberger et al., 2013; Gawler et al., 2016; Hwang et al., 2016; Yamada et al. 2013). For instance, the sample size in the study by Hwang et al. (2016) was 456 older adults and that in the study by Gawler et al. (2016) was 1256 subjects, implying that these samples were sufficiently powered and were representative of the target population, making it possible to generalize the results of these studies to general populations. Some of the studies were conducted for long duration (12-24 weeks), allowing adequate time for the investigators to evaluate the intervention outcome (Freiberger et al. 2013; Gawler et al., 2016; Hwang et al., 2016; Josephs et al., 2016; Kloubec et al., 2012; Zhuang et al., 2014).  

            However, there were also some weaknesses. First, most of the studies used very small sample sizes, implying that they were not representative and were under-powered to detect any changes in the study groups. This may limit the generalizability of those studies to other populations (Josephs et al., 2016; Kloubec et al., 2012; Lacroix et al., 2016); Song & Kim, 2015; Zhao et al. 2017; Zhuang et l., 2014). Second, there was lack of blinding for participants in some RCTs, creating a likely bias (Freiberger et al. 2013; Yamada et al. 2013), making it difficult to compared the intervention to usual care. Third, there was lack of follow-up in some studies and this made it difficult to investigate the intervention effects on actual rates of falling in those studies (Zhuang et al., 2014). Furthermore, some studies had significantly high attrition, which introduces bias (Gawler et al., 2016; Hwang et al. 2016).

 Relevant Data

Author(s)/Date Study Design Sample and Sample Size Intervention  Outcomes     Results
Song & Kim (2015) Randomized controlled trial (RCT)

 

Older adults aged ≥65 years (N=40) Complex exercise comprising os aerobic and resistance exercises Falls efficacy

Walking ability during direction change

 Significant increase in the falls efficacy scale and figure-of-8 walk test step scores in the complex exercise group than the general exercise group
Lacroix et al. (2016) RCT

 

Healthy older adults (N=66) Twelve-weeks balance and strength training (BST) program Static and dynamic  steady-state, proactive and reactive balance

Lower extremity muscle power

The BST was feasible and safe. Improvements in balance were in favor of the supervised group
Pai et al. (2014) RCT

 

Community-dwelling older adults ≥65 years (N=109) Systematic perturbation training , with exposure to 24 unannounced repeated slips Rates of falls Exposure to 24 repeated slips were 2.3 times less likely to fall than controls, who experienced a single slip
Zhuang et al. (2014) RCT

  

Community-dwelling older adults  aged 60-80 years (N=56) combined exercise program comprising SBT and the 8-form Tai Chi Chuan Physical performance

Isokinetics and gait

The intervention group has a 17.6 percent improvement in timed up and go test and 54.7 percent in 30-seconf chair stand test.
Freibeger et al. (2013) Cluster RCT

 

Community-dwelling older adults (N=378) Complex exercise intervention  program Physical function, strength and balance

Fear of falling

Improvement in the TUG, balance and reduced fear of falls were demonstrated in the intervention group compared to the control
Dadgari et al. (2015) RCT

 

Elderly community dwellers (N=317) OEP, a home-based exercise training program Physical performance

Timed-Up-Go-Test

Functional capacity

Chair-Stand-Test

OEP improved functional capacity and physical performance in the intervention group

Fall incidence was also significantly reduced

Hwang et al. (2016) RCT

 

Older adults ≥60 years (N=456)  TCC or LET for six months Fall measures: recurrent fallers, fallers, time to first fall, falls The risk of falls was lower in the TCC group compared with the LET group (IRR=0.30, 95% CI=0.14-0.71). TCC group also experienced greater improvement in cognitive function than the LET group
Yamada et al. (2013) RCT

 

Community-dwelling older adults aged ≥65 years (N=264). Community-based MTS programs combines with standardized multicomponent exercise program Number of falls

Fall-related fractures

Stepping accuracy

Gaze behavior

Risk of falls

The number of falls was lower in the intervention group (13%) compared with the control group (33%) (IRR=0.35, 95% CI=0.19-0.66)
Josephs et al. (2016) RCT

  

Community-dwelling older adults (N=31) Pilates exercise program Balance confidence

Balance measures

Fall risk

 

Significant improvements were noticed in the Fullerton Advanced Balance Scale in PG and TG

Significant improvement in Activities-Specific Balance Confidence Scale were also noticed in the PG group

Gawler et al. (2016) Cluster-RCT

 

Community-dwelling elderly aged ≥65 years (N=1256) OEP and FaME Fall risk

Fall-related injuries

Balance

The FaME group experienced lower incidence of falls and reduction I  injurious falls (IR 0.55, 95% CI 0.13, 0.96, p=0.04) compared to usual care group

 

Synthesis and Interpretation

            This paper sought to explore the effectiveness of physical exercise in decreasing fall incidence in older adults without cognitive impairment. The common finding is that exercise is superior to usual care in reducing the risk of falls and fall-related injuries in the elderly. It is believed that physical exercise prevents falls by improving various fall-related outcomes, including walking ability during direction change (Song & Kim, 2015); lower extremity muscle power, proactive and reactive balance and dynamic and static steady-state (Ferreira et al., 2014; Kloubec et al., 2012;  Lacroix et al., 2016); physical strength and function (Freibeger et al., 2013); and gaze behavior, stepping accuracy and balance confidence (Josephs et al., 2016); and balance perception (Kloubec et al., 2012); as well as reducing fear of falling (Feibeger et al., 2013).

            The modality of exercise program implemented seems to affect the risk of falls, with same modalities being more effective than others. An example of the widely investigated exercise program is the Otago Exercise Program (OEP), which is a balance and strength retraining program, coupled with walking. The OEP has demonstrated effectiveness in improving balance and preventing falls in older adults (Dadgari et al., 2015). However, while comparing the group-based exercise program (FaME) and home-based exercise program (OEP) with usual care, Gawler et al. (2016) found out that FaME was more effective than OEP exercise in reducing falls in older adults. However, the findings of this study should be interpreted cautiously because of the high attrition (52 percent) that took place during the study.              Researchers have also sought to offer efficient and interesting exercise modalities for older adults. For instance, Song and Kim (2015) implemented a complex exercise program comprising of aerobic and resistance exercises and found that this exercise modality improved fall efficacy and walking ability in older adults. These findings are supported by Freiberger et al. (2013) who showed that a complex exercise intervention successfully reduced psychological and physiological fall risk factors in the elderly. Zhuang et al. (2014) demonstrated that an innovative combined exercise intervention was effective in improving physical fitness and reducing the risk of falls in older adults. In another study, Pai et al. (2014) implemented perturbation training and found that this exercise modality reduced the annual risk of fall in community-dwelling older adults by improving resilience to postural disturbances. This finding supports previous research that training can reverse the functionality and strength of muscles in the elderly (Kloubec et al., 2012).

            Pata et al. (2013) explored the effect of Pilates based exercise program and found out that such a program was effective in improving postural stability, mobility, and balance, thereby decreasing the risk of falls in older adults. Similarly, Josephs et al. (2016) found that Pilates exercise program was effective in improving balance confidence.  However, they did not find any statistically significant difference between Pilates exercise program and traditional exercise program in relation to balance measures, specifically the Fullerton Advanced Balance Scale (Josephs et al., 2016). In another study, Hwang et al. (2016) found out that a guided home-based tai chi chuan (TCC) exercise program was more effective than the conventional lower extremity training (LET) in reducing fall incidence in older adults.  

Conclusion

            Falls remain a major healthcare problem in older adults due to age-related functional decline. Falls are associated with significant morbidity and mortality as were as pain and reduced quality of life. Therefore, preventing falls is of paramount importance in nursing practice(Kloubec et al., 2012. This review sought to explore the effectiveness of physical exercise in reducing the incidence of falls in older adults without cognitive impairment. The consistent finding from the reviewed literature is that physical exercise seems to be effective in reducing fall incidence in older adults without cognitive impairment. Physical exercise achieves this outcome by improving physical muscle strength and function, gait, walking stability, and posture as well as improving balance confidence and reducing the fear of falling. Various exercise modalities have demonstrated effectiveness in this regard, including Pilates exercise, complex exercise intervention, combined exercise program, the OEP, TCC, FaME, LET, and BST among others. While most of these exercise modalities have been found to be more effective than usual care in reducing the risk of falls in older adults, some factors are believed to influence their effectiveness. For, instance, supervision is believed to influence compliance with exercise programs, thereby affecting fall-related outcomes (Lacroix et al., 2015). It is also important to mention that most of the reviewed studies used very small sample sizes, which may limit the generalizability of their findings to the general population. Additional factors should be taken into account when interpreting the findings of studies on the effectiveness of exercise programs in reducing the risk of falls in the elderly. These factors may include the duration of study, presence or absence of follow-up, and adherence to the exercise program (Freiberger et al., 2013).  Based on this evidence, an evidence implementation plan based on a physical exercise program is recommended to help reduce the risk of falls in older adults.

 

References

Bullo, V., Bergamin, M., Gobbo, S., Sieverdes, J. C., Zaccaria, M., Neunhaeuserer, D., & Ermolao, A. (2015). The effects of Pilates exercise training on physical fitness and     wellbeing in the elderly: A systematic review for future exercise prescription. Preventive         Medicine, 75, 1-11.

 Dadgari, A., Hamid, T. A., Hakim, M. N., Chaman, R.M Mousavi, S. A., Hin, L. P., & Dadvar, L. (2016). Randomized Control Trials on Otago Exercise Program (OEP) to Reduce Falls      Among Elderly Community Dwellers in Shahroud, Iran. Iranian Red Crescent Medical   Journal, 18(5), 11-19.

El-Khoury, F., Cassou, B., Charles, M-A., & Dargent-Molina, P. (2013). The effect of fall            prevention exercise programmes on fall induced injuries in community dwelling older    adults: systematic review and meta-analysis of randomised controlled trials. British   Medical Journal, 2013, 347-359.

Ferreira, M. P., Israel, V. L., & Guimaraes, A. T. B. (2014). Effects of Functional Exercise            Program on Balance in the Institutionalized Elderly. Topics in Geriatric Rehabilitation,             30(4), 276-281.

 Freiberger, E., Blank, W. A., Salb, J., Geilhof, B., Hentschke, C., Landendoerfer, P.,…Siegrist,   M. (2013). Effects of a complex intervention on fall risk in the general practitioner       setting: a cluster randomized controlled trial. Clinical Interventions in Aging, 8, 1079–        1088.

Gawler, S., Skelton, D. A., Dinan-Young, S., Masud, T., Morris, R. W., Griffin, M.,…Iliff, K. S. (2016). Reducing falls among older people in general practice: The ProAct65+ exercise          intervention trial. Archives of Gerontology and Geriatrics, 67, 46–54.

Hwang, H-F., Chen, S-J., Lee-Hsieh, J., Chien, D-K., Chen, C-Y., & Lin, M-R. (2016). Effects    of Home-Based Tai Chi and Lower Extremity Training and Self-Practice on Falls and          Functional Outcomes in Older Fallers from the Emergency Department—A Randomized   Controlled Trial. Journal of American Geriatrics Society, 64, 518–525.

Josephs, S., Pratt, M. L., Meadows, E. C., Thurmond, S., & Wagner, A. (2016). The          effectiveness of Pilates on balance and falls in community dwelling older adults. Journal         of Bodywork & Movement Therapies, 20, 815-823.

Kloubec, J. A., Rozga, M., & Block, M. Balance Improvements in Independent-Living Elderly     Adults Following a 12-Week Structured Exercise Program. Activities, Adaptation &       Aging, 36(2), 167-178.

Kuptniratsaikul, V., Praditsuwan, R., Assantachai, P., Ploypetch, T., & Udompunturak, S.            (2011). Effectiveness of simple balancing training program in elderly patients with             history of frequent falls. Clinical Interventions in Aging, 6, 111–117.

Lacroix, A., Kressig, R. W., Muehlbauer, T., Gschwind, Y. J., Pfenninger, B., & Bruegger, O., &             Granacher, U. (2016). Effects of a Supervised versus an Unsupervised Combined Balance       and Strength Training Program on Balance and Muscle Power in Healthy Older Adults:            A Randomized Controlled Trial. Gerontology, 62, 275–288.

Martin, J. T., Wolf, A., Moore, J. L., Rolenz, E., DiNinno, A., & eneker, J. C. (2013). The             Effectiveness of Physical Therapist–Administered Group-Based Exercise on Fall      Prevention: A Systematic Review of Randomized Controlled Trials. Journal of     Geriatrics Physical Therapy, 36, 182 – 193.

 Mulligan, N. F., Tschoepe, B. A., & Smith, M. B. (2014). Balance Retraining in Community-       Dwelling Older Adults: Highlights of Interventions Strategies That Hold Promise in            Physical Therapy Practice. Topics in Geriatric Rehabilitation, 30(2), 117-126.

Pai, Y-C., Bhatt, T., Yang, F., & Wang, E. (2014). Perturbation Training Can Reduce        Community-Dwelling Older Adults’ Annual Fall Risk: A Randomized Controlled Trial.    Journal of Gerontology Series A: Biological Sciences and Medical Sciences, 69(12),          1586-1594.

Pata, R. W., Lord, K., & Lamb, J. (2014). The effect of Pilates based exercise on mobility,            postural stability, and balance in order to decrease fall risk in older adults. Journal of             Bodywork & Movement Therapies, 18, 361-367.

Song, H. S., & Kim, J. Y. (2015). The effects of complex exercise on walking ability during          direction change and falls efficacy in the elderly. Journal of Physical Therapy and    Science, 27, 1365–1367.

Trombetti, A., Har, M., Herrmann, F. R., Kressig, R. W., Ferrari, S., & Rizzoli, R. (2011). Effect of Music-Based Multitask Training on Gait, Balance, and Fall Risk in Elderly People: A      Randomized Controlled Trial. Archives of Internal Medicine,171(6),525-533.

Yamada, M., Higuchi, T., Nishiguchi, S., Yoshimura, K., Kajiwara, Y., & Aoyama, T. (2013).      Multitarget Stepping Program in Combination with a Standardized Multicomponent     Exercise Program Can Prevent Falls in Community-Dwelling Older Adults: A          Randomized, Controlled Trial. Journal of American Geriatrics Society, 61, 1669–1675.

Zhao, Y., Chung, P-K., & Tong, T. K. (2017). Effectiveness of a balance-focused exercise            program for enhancing functional fitness of older adults at risk of falling: A randomised           controlled trial. Geriatric Nursing, 20, 1-7.

Zhuang, J., Huang, L., Wu, Y., & Zhang, Y. (2014). The effectiveness of a combined exercise      intervention on physical fitness factors related to falls in community-dwelling older            adults. Clinical Interventions in Aging, 9, 131–140.    

 

 

 

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