Falls are a common and often devastating clinical problem faced by older people, causing a tremendous amount of morbidity, use of health care services including premature nursing home admissions, and mortality (Rubenstein, 2006). Many older adults develop a fear of falling that causes them to limit their physical activity (PA) and social interactions, creating a “domino-effect” that results in reduced mobility, physical weakness and decline, and feelings of isolation and depression (Altarum Institute, 2012). A couple of weeks ago, I participated in a course at the Osher Lifelong Learning Institute (OLLI-UGA) where the topic “Fall prevention: could you get up after a fall” was presented by Dr. Ellen Evans.
She explained that falls are associated with identifiable risk factors (e.g., decreased sensory function, weakness, unsteady gait, certain medications, posture hypotension and confusion, and environment). Once the factors have been identified, health practitioners and patients can work on the modifiable ones, which may significantly reduce rates of falling and the incidence of injuries and trauma-related hospital admissions in that population.
There have been some proven evidence-based strategies, including home modifications –to identify hazards-; exercise-based programs focused on improving range of motion, coordination, balance, endurance, muscle strength and aerobic capacity; and use of safety devices and mobility aids. Some of them include Stopping Elderly Accidents, Deaths & Injuries program (STEADI, a CDC initiative), and Go4Life (an NIH and NIA initiative). Overall, exercise programs are one of the most cost-effective actions to diminish the risk of falling and it could also help with others co-morbidities related to fall history (e.g., diabetes, Meniere’s disease, sarcopenia, arthritis).
Despite these proven advantages and the tons of health benefits, the majority of older adults do not achieve the recommended amount of PA, and many are inactive altogether. As can be seen, when it comes to prescribing exercises for fall prevention, there are several tools that practitioners have. They can be implemented either identifying unsafe behaviors and recommending modifications or offering effective interventions prescribing exercise programs that target health-related physical fitness components whenever we have the opportunity to work with seniors. Specifically, Dr. Evans recommends following the same PA guidelines for adults plus balance, coordination and agility activities, with special attention to overloading and progression aspects. Concerning, a physical exertion scale from 1 to 10 can be used, considering the intensity from 5 to 6 for moderate intensity activities and from 7 to 8 for vigorous.
References
Altarum Institute (September, 2012). Recommendations to Promote Health and Well-Being Among Aging Populations, pp 1-16. Retrieved fromhttp://healthyamericans.org/assets/files/Prevention%20Recommendations%20for%20Aging%20Populations2.pdf
Rubenstein, L. Z. (2006). Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing, 35-S2, ii37-ii41. Retrieved fromhttp://centerforhealthyhousing.org/Portals/0/Contents/Article0785.pdf
Thanks for your comment! Millions of aging baby boomers that will have reached the age of 65 in the next ten years raise the importance of attending this population. It is interesting that you mentioned America’s obesity epidemic and sarcopenia as a comorbidity associated with aging because, indeed, this last one condition was mentioned by Dr. Evans in her lecture. She mentioned that sarcopenic obesity is characterized by the presence of both high fat mass and loss of muscle mass, and detailed how it can lead to physical disability, functional limitations, and mortality, especially in older adults. It is due to the commonly associated loss of muscular strength (i.e., dynapenia). Therefore, I think these variables would be an important aspect to be targeted for future interventions in this population.
I agree that falls are a major concern for the elderly. Researching effective prevention measures is a worthwhile endeavor considering the increasing age of the population. I did not know that there were concrete risk factors that were related to fall risk, and I wonder how often primary care physicians examine these traits in their patients. I also wonder if there is any type of screening tool available to assess fall risk, in order to make it easier for a physician to capture this information before meeting with the patient.
It makes sense that the most effective approach to reducing these risk factors would be physical activity, yet we know that older adults do not get enough. Did Dr. Evans speak to any specific barriers that older adults cite to physical activity and ways the remove those barriers? If assessing barriers/facilitators of physical activity in older adults has not been examined, I think it would be an important topic for further research. Additionally, although the recommendations for physical activity are the same, I would think that this population would need more specific recommendations and programs to help increase self-efficacy. Perhaps doctor’s offices could provide pamphlets with at-home exercises or at least a flyer with website resources. Knowing that this is a major problem among older adults, I think more measures should be taken to raise awareness of the need to exercise and provide activities to improve mobility, balance, and quality of life to more older adults.
Hi, Emily! Indeed, there are specific screening tools and algorithms available for healthcare providers to assess fall risk. One of them is available here: https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-print.pdf as a part of the Stopping Elderly Accidents, Death, and Injuries (STEADI) program of CDC.
Additionally, findings obtained by both quantitative (e.g., physical activity barriers scales) and qualitative (e.g., interviews and focus groups) techniques have shown that older adults may refrain for multiple reasons, such as costs associated with the participation or enrollment in physical activity programs, lack of transportation, and health and safety concerns or fears. The good news is that there are also facilitators to enhance participation in exercise and physical activity programs and fostering relationships among older participants, such as offering programs at residential sites and nursing homes, educating families about the importance of physical activity for older adults and ways they could help, offering low- or no-cost classes, involving older adults in program development, and providing individualized and tailored exercises (Belza et al., 2004). Thanks for your comment!
Reference
Belza, B., Walwick, J., Schwartz, S., LoGerfo, J., Shiu-Thornton, S., & Taylor, M. (2004). Older Adult Perspectives on Physical Activity and Exercise: Voices From Multiple Cultures. Preventing Chronic Disease, 1(4), A09.
As the United States’ population continues to age, knowledge of and participation in regular physical activity that promotes fall prevention should be an important concern, especially in the context of America’s obesity epidemic and the resulting comorbidities associated with aging, like sarcopenia, osteoporosis, and decreased independence leading to sedentary life styles. I think that an additional fall prevention program that should be mentioned as part of this post is the Otago Exercise Program. Otago is an evidence-based fall prevention program that was started in New Zealand and has since become a popular prescription among physical therapists. Numerous factors make Otago a preferable program to most, namely its focus on increasing strength and retraining balance. Once participants have improved these factors, a physical activity component is implemented in which participants are directed to walk thirty minutes per day, at least two days per week. Additional advantages of Otago include its adaptability, individualization, implementation and progression, and its cost effectiveness. Maintaining these improvements to sustain the benefits of Otago is the end goal of the program and can be monitored through various strategies involving the individual’s PCP, family members, and continuing to use the program’s outcome measures to determine further progress, including the Four-Test Balance Scale and Chair Stand Test. For more information on Otago, please reference this PDF booklet of the entire program: https://www.acc.co.nz/assets/injury-prevention/acc1162-otago-exercise-manual.pdf
I couldn’t agree with you more about the tole a fall can have an elderly person, and depending on the age and other health conditions, could be a life threatening event. With that in mind, prevention is obviously the best way to keep something like this from happening, which can be easy for those that are able to be active. Some form of physical activity is going to be the best way to keep muscle strength, endurance and proprioception in check. But what do you do when you have a patient with to many complications with their health to be able to properly exercise? Take the example of someone with a heart condition and an orthopedic knee condition such as a torn meniscus. They won’t be able to do much activity on their feet, and can’t get a surgery to repair the knee due to their heart and being in blood thinners? What other kind of options are there for a person like this? I did also like the discussion of changing the environment, because again for some patients, physical activity alone will not be alone. A patient with osteoporosis may be very physically active, but could still easily suffer broken bone without even falling, and in severe cases physical activity alone could be discourage because of their bone density, so altering the environment is the best option for them. I’d be interested to hear some of the environment alterations they recommended.
Hello, Anthony. I appreciated your comment! And that is true! Prevention exercises and tasks can be easy for those that are still independent and able to be active. Luckily, there is more than one way to stimuli different physical components related to fall prevention. There are also several exercise options and moves that can be implemented for optimizing patient’s functionality. In the past, when I had the opportunity to work with persons with common comorbid conditions –including older adults-, I had successful experiences following and adapting some of the recommendations from the book ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. I recall that I had got the third edition, but looking at there is a new one. There are other available resources about exercise prescription and medications that, as you mentioned, is another important issue when we work with seniors. I think that as practitioners, and once the participants have gotten a medical clearance, we have the possibility to be creative and versatile because there is a vast variety of exercise adaptations and progressions that can be implemented, yet always following some basic safety principles as constantly monitoring.
Overall, the speaker also suggested some recommendations that older adults can follow to be a wise mover, for example, consider an assistive device, respect surfaces (e.g., slippery or soapy), be careful with some outdoor conditions (e.g., wind, rain, fog, sun), wear smart shoes (e.g., no big heels or backless), review medications, get enough sleep, mind the alcohol, stand up slowly, and last but not least, if a fall does happen, tell to the doctor!