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July/August 2021
Fall Prevention: Targeted Exercise Reduces Risk With age, the risk of falling increases and the ability to bounce back after a fall decreases. According to the Centers for Disease Control and Prevention (CDC), 36 million older adults fall each year—and more than 32,000 die from fall-related complications. Every year, 3 million older adults visit emergency departments for injuries from a fall. One in five falls causes a serious injury, such as a broken bone or head trauma, and more than 95% of hip fractures in older adults result from a fall. And, after falling once, the chance of falling again is doubled.1 Many older adults may never fully recover from a fall, suffering reduced mobility, decreased quality of life, and further health decline. Numerous other factors besides age and previous falls contribute to the risk of falling in older adults. The CDC notes that most falls are caused by the interaction of multiple risk factors—the more risk factors, the greater the risk of falling. These other risk factors can include the following: • use of certain medications; A February 2021 study found that older adults with markers of frailty (eg, fatigue, weakness, weight loss, low physical activity, poor balance, and cognitive impairment) are as much as 53% more likely to experience multiple falls.2 Several of these risk factors for falling can be addressed with regular exercise; improving strength, balance, and flexibility can help reduce the likelihood of falling and fall-related injuries. Targeting exercise specifically for fall prevention can reduce fall risk even more. Research has shown that exercise is the most effective intervention for fall prevention in older adults. In general, more active older adults have a lower risk of falling than do those who are less active, and popular exercise activities for older adults, such as low-impact aerobics, tai chi, strength training, and yoga, can provide benefits related to balance, coordination, and flexibility that help to prevent falls. Recent research has also highlighted the most effective exercises for fall prevention. A November 2020 pooled analysis of 116 randomized controlled trials that included 25,160 participants aged 60 years or older found that exercise reduced the rate of falls by 23%. Subgroup analyses found that different types of exercise were associated with the same or greater reductions in fall risk. Tai chi reduced fall risk by 23%. Balance and functional exercises were associated with a 24% reduction. A combination of balance and functional exercises with resistance training was found to reduce fall risk by 28%. Performing three or more hours weekly of balance and functional exercises was found to reduce falls by 42%.3 Another November 2020 analysis also evaluated the comparative effectiveness of fall prevention exercise interventions.4 “We analyzed data from 73 studies including more than 30,000 participants to identify effective components of fall prevention exercise. We found that the most effective exercise for reducing the number of older adults who fall included four types of balance—anticipatory, reactive, dynamic, and functional—as well as flexibility,” explains Kathryn Sibley, PhD, Canada Research Chair in Integrated Knowledge Translation in Rehabilitation Sciences, an associate professor at the University of Manitoba, and lead author of the meta-analysis. Sibley and her colleagues reviewed and analyzed randomized controlled trials comparing different exercise types or comparing exercise with no exercise or usual care to evaluate number of older adults who fell and fall injuries. The mean age of study participants ranged between approximately 65 and 92 years.4 Five exercise components were found to be most effective for reducing the number of older adults who fall, including flexibility and the following four components of balance—balance being defined as the ability to maintain control of one’s center of mass in relation to a base of support4: • functional stability, defined as the ability to move one’s center of mass as far as possible in any direction within the base of support (eg, being able to reach for something without losing balance); • dynamic stability, defined as the ability to maintain one’s center of mass position when the base of support changes (eg, moving from seated to standing, or when walking); • anticipatory control, defined as the ability to move one’s center of mass position in advance of a voluntary movement that would otherwise cause instability (eg, walking up steps); and • reactive control, defined as the ability to recover stability after one’s center of mass moves beyond the base of support (eg, stopping oneself from falling after tripping). “This analysis is very exciting because for the first time we have unlocked the key ingredients for fall prevention exercise. We can use this information to design more precise exercise programs that target these critical components and more effectively help older adults stay mobile and active by preventing more falls,” Sibley notes. Those working with geriatric patients can incorporate these components of balance and flexibility into exercise programs for older adults, Sibley emphasizes. In their analysis, Sibley and her colleagues listed some sample exercises that target each balance component (see table).
In combination with flexibility exercises, such as stretching and gentle yoga, exercises homing in on the four balance components identified by Sibley and her colleagues may improve the effectiveness of existing fall prevention programs. Many of these programs already include such components, as do fitness classes geared toward older adults, such as Silver Sneakers, and tai chi. These balance exercises can also be combined with resistance training to improve muscular strength and bone density, as well as provide a challenge for more active older adults. For example, adding a handheld weight or a resistance band to a standing twist and reach exercise adds core and upper body strengthening to a balance exercise that targets functional and dynamic stability and anticipatory control. Holding weights while rising from seated position to standing or doing heel raises adds lower body muscular strength and endurance to a balance exercise that targets dynamic stability and anticipatory control. Tossing weighted bean bags or bouncing and catching a lightweight medicine ball adds upper body strengthening to a reactive control exercise.5 Unfortunately, those older adults who most need to exercise for fall prevention tend not to. It may be more challenging to motivate less active and frailer older adults to exercise. In a group fitness setting, less active and frailer older adults may view more active and fit participants as intimidating. Or, even though most exercises can be adapted to a lower level of fitness or to chair exercises, frail older adults may feel self-conscious or embarrassed to need modifications, which may prevent them from accessing appropriate programs. And, ironically, a fear of falling is a common barrier to exercising for fall prevention, especially in older adults who have fallen previously, have a medical condition or disability, or experience depression.6 Research suggests that initiatives to increase fall prevention awareness in the community setting and stressing its importance to those who care for geriatric populations (eg, assisted living facility staff, primary care providers) can help improve older adult participation in fall prevention exercise programs. For example, church-based and community recreation center fall prevention information and classes, as well as programs delivered in the primary care setting, have been shown not only to improve access to and participation in fall prevention but also to reduce fear of falling.6-8 Given that targeted exercise programs are the most effective intervention to prevent falls, expanding awareness and access to them is essential to reduce the high number of older adults who fall each year and the consequences of those falls. — Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.
References 2. Jehu DA, Davis JC, Falck RS, et al. Risk factors for recurrent falls in older adults: a systematic review with meta-analysis. Maturitas. 2021;144:23-28. 3. Sherrington C, Fairhall N, Kwok W, et al. Evidence on physical activity and falls prevention for people aged 65+ years: systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act. 2020;17(1):144. 4. Sibley KM, Thomas SM, Veroniki AA, et al. Comparative effectiveness of exercise interventions for preventing falls in older adults: a secondary analysis of a systematic review with network meta-analysis. Exp Gerontol. 2021;143:111151. 5. Signorile JE. Targeted resistance training to improve independence and reduce fall risk in older clients. ACSMs Health Fit J. 2016;20(5):29-40. 6. Lavedán A, Viladrosa M, Jürschik P, et al. Fear of falling in community-dwelling older adults: a cause of falls, a consequence, or both? PLoS One. 2018;13(3):e0194967. 7. Clark L, Thoreson S, Goss CW, et al. Older adults' perceptions of a church-based social marketing initiative to prevent falls through balance and strength classes [published online January 6, 2021]. J Appl Gerontol. doi: 10.1177/0733464820984288. 8. Siegrist M, Freiberger E, Geilhof B, et al. Fall prevention in a primary care setting. Dtsch Arztebl Int. 2016;113(21):365-372. |
