the role of exercise in fall prevention for older adults

8/9/2019 The Role of Exercise in Fall Prevention for Older Adults

1/25

T h e R o l e o f E x e r c i s ei n F a l l P r e v e n t i o n

f o r O l d e r A d u l t sDebra J. Rose, PhD*, Danielle Hernandez, MS

Regular participation in physical activity or exercise is not only integral to the mainte-nance of good health and functional independence in older adulthood,1 but alsoserves a primary role in the prevention of numerous chronic diseases (eg, type 2 dia-betes, cardiovascular disease, osteoporosis, certain types of cancer)2 and cognitivedecline.3 Conversely, inactivity doubles the risk of developing a disability that willadversely affect mobility as well as the ability to perform even the most basic activitiesof daily life. This downward spiral in physical function ultimately results in heightenedrisk for both loss of functional independence and falls.4

Depending on the level of risk identified, physical activity or exercise may servea primary, secondary, or tertiary role in the prevention of falls.5 In its primary role,regular engagement in physical activity can prevent the onset of pathological condi-tions and system impairments that may lead to disability and heightened risk for falls.Slowing the progression of disease and system impairments is physical activity’ssecondary role, while its tertiary role, for those older adults who have reached a levelof system impairment or disease progression that can no longer be slowed, lies in therestoration of function to a level that allows for as much autonomy as possible in theperformance of basic daily activities.

THE BENEFITS OF PHYSICAL ACTIVITY (AND EXERCISE) IN REDUCING FALLS:OVERVIEW OF RESEARCH FINDINGS

As of 2009, more than 600 published articles have investigated various interventionstrategies aimed at lowering fall rates and/or fall risk among older adults. Of themultiple strategies investigated, exercise, either as a stand-alone intervention strategyor as an important component of a multifactorial intervention strategy, has beendescribed as one of the “best buys” in fall prevention.6 Intervention strategies have

Department is Kinesiology, Center for Successful Aging, California State University, Fullerton,800 North State College Boulevard, Fullerton, CA 92834, USA* Corresponding author.E-mail address: [email protected]

KEYWORDS

Exercise Older adults Fall prevention Community Hospitals Long-term care

Clin Geriatr Med 26 (2010) 607–631doi:10.1016/j.cger.2010.07.003 geriatric.theclinics.com0749-0690/10/$ – see front matter 2010 Elsevier Inc. All rights reserved.

mailto:[email protected]://geriatric.theclinics.com/http://geriatric.theclinics.com/mailto:[email protected]


2/25

employed single (eg, resistance training, aerobic endurance) or multiple categories of exercise (eg, resistance and balance/gait training). Some interventions have adopteda general approach (eg, walking), whereas others have been tailored to address thespecific risk factors contributing to the heightened fall risk (eg, muscle weakness,balance and gait impairments, reduced flexibility, and/or aerobic endurance). In addi-tion to the different types of exercise, the target audience (eg, healthy but sedentary,frail), method of delivery (ie, group-based versus one-to-one), and intervention setting(ie, community and/or home, acute and subacute, long-term care) have also differedacross studies.7,8

Community and Home Settings: Stand-Alone Exercise Approaches

The multicenter FICSIT (Frailty and Injuries: Cooperative Studies on Intervention Tech-niques) randomized controlled trials represented the first systematic and large-scaleattempt to investigate the efficacy of exercise (both targeted and nontargeted) on

a mutually agreed-on set of perf ormance measures related to frailty as well as fall inci-dence rates among older adults.9 Although the interventions varied with respect to thetype of exercise used and the intensity, frequency, and duration of the intervention, thecombined multisite outcomes demonstrated a significant reduction in the risk of fallingfor the interventions that included exercise as a core component (ie, 13% reduction).The risk of falling was further reduced (ie, 24% reduction) if the exercise interventionincluded specific balance and gait activities.9

More than 100 additional exercise trials have been published since that time,showing different types of exercise programs to be effective in reducing the rate of falls as well as fall risk. In a recently published Cochrane review, Gillespie and

colleagues7

examined the efficacy of 43 exercise-only trials in reducing rate of falls(ie, number of falls per person year) and risk of falling (ie, number of people who fellone or more times during the follow-up period) in older adults residing in the commu-nity. Using the Prevention of Falls Network Europe (ProFaNE) taxonomy of exercise,10

the investigators examined the effectiveness of exercise programs that includeda single category of exercise (eg, balance/gait, strength/resistance training), programsthat included multiple categories of exercise (eg, balance/gait, strength/resistance,flexibility), 3-dimensional exercise programs (eg, tai chi, dance), and general physicalactivity (eg, walking) in reducing fall risk and falling rates.

Multicomponent (2 or more exercise categories) group-based programs were effec-

tive in significantly lowering fall incidence rates (14 trials) among older adults, irrespec-tive of their baseline fall risk level (higher versus lower), whereas the risk of falls (17trials) was lowered, albeit not significantly, for older adults at a higher level of fallrisk only. Similarly, individually tailored exercise programs that included multiple exer-cise components and were delivered in the home significantly lowered fall incidencerates (4 trials) and fall risk (3 trials). Tai chi interventions were also shown to be effectivein lowering fall incidence rates (4 trials) as well as fall risk (4 trials). In contrast to thesignificant outcomes for exercise trials combining multiple categories of exercise(including tai chi), single-category exercise programs were not as effective. Exerciseinterventions that focused on balance/gait activities alone were effective in lowering

the rate of falls (3 trials) but not fall risk (3 trials), whereas interventions that were limitedto strength/resistance exercises did not result in positive fall-related outcomes, irre-spective of whether the program was group-based or individually tailored. Similarly,more general physical activities such as walking (2 trials) did not lead to any significantreductions in fall incidence rates or fall risk.

As promising as these findings are when community-residing older adults with nocomorbid conditions or cognitive impairment are the targeted groups, no evidence

Rose & Hernandez608


3/25

wasprovided that structured group or home-based exercise lowered fall rates or fall riskamong older adults with visual impairment11 or Parkinson’s disease,12 or among olderadults experiencing balance and gait problems following a stroke13 or hip fracture.14

Reasons advanced by the investigators to explain the nonsignificant findings in thesestudies included insufficient dose of exercise,12–14 low levels of adherence to the exer-cise,11 and/or other intervention strategies being more effective for the group studied.11

Community and Home Settings: Multifactorial Approaches

Given that more than 60% of all falls experienced by older adults residing in the commu-nity result from an interaction among multiple fall risk factors,15 it is not surprising thatmultifactorial intervention strategies that include exercise as a core component areconsidered to be the most effective method for reducing falls, particularly when olderadults at high risk for falls are targeted.16 The primary goal of these types of strategiesis usually to identify and then ameliorate or manage known fall risk factors using

a systematic follow-up process. The most common fall risk factors targeted includegait and balance impairments, muscle weakness, number and type of medications,cardiovascular risk factors, vision, and environmental hazards in the home.

Tinetti and colleagues17 conducted one of the first studies that adopted a multifac-torial approach to reducing fall incidence rates. Men and women living in the commu-nity with at least one risk factor associated with falling participated in a multifactorialintervention aimed at eliminating or managing identified risk factors (eg, medicationuse, gait and balance, postural hypotension, home hazards). Their results indicatedthat fewer participants in the intervention group when compared with a control groupthat received usual health care and social visits only, fell during the 1-year follow-up

period (35% vs 47%, respectively). The investigators also provided evidence for theintervention’s cost-effectiveness.18

Building on the success of this original work, Tinetti and colleagues19 compared therates of serious fall-related injuries among older adults (70 years or older) in 2 regions(intervention, usual care) of Connecticut using a nonrandomized design. The regionswere identified on the basis of whether clinicians had been exposed to multifactorialrisk assessment and intervention practices similar to those used in the Yale FICSIT trial(ie, intervention region) or had received no such exposure (usual care region). Twofindings of particular note were the lower rates (9%) of serious falls recorded amongolder adults in the intervention region during the 2-year evaluation period and

a decrease (11%) in the use of medical services for fall-related reasons in the sameregion when compared with the usual care region. According to the investigators,this decrease in the need for fall-related medical services “translated into approxi-mately 1800 fewer emergency department visits or hospital admissions.”19(p260) Theresults of this study clearly demonstrate that clinicians from multiple disciplines whoare exposed to evidence-based practice can successfully implement it into their clin-ical practice. More recently, Baker and colleagues20 have begun to test the feasibilityof implementing “Step By Step,” a multifactorial program that includes the corecomponents of the earlier Yale FICSIT trial17 in senior centers in Connecticut. Theirpreliminary results suggest that senior centers may also be suitable venues for imple-

menting fall prevention programming that adopts a multifactorial approach.

Acute and Subacute Care Settings: Stand-Alone Exercise and

Multifactorial Approaches

Admission to hospital is associated with an increased risk of falling among olderadults. A new diagnosis (eg, hip fracture, stroke) coupled with the unfamiliarity of a hospital environment often results in a higher incidence of falls. Prescription

Fall Prevention for Older Adults 609


4/25

medications intended to lower anxiety or provide sedation further increase the imme-diate risk of falls among patients in acute care facilities.8 Although fewer publishedstudies have investigated the efficacy of different intervention strategies aimed atlowering fall rates and/or fall risk in these settings, a recent Cochrane review8 summa-rized the findings of 11 studies conducted in acute,1 subacute,6 and a combination of the 2 settings.4 Three studies investigated exercise as a stand-alone interventionstrategy in subacute settings while 2 studies investigated a multifactorial interventionstrategy that included exercise as a core component. The characteristics and findingsof the individual studies examined in the review that included exercise as a stand-alone intervention strategy or as part of a multifactorial strategy are summarized inTable 1.

Collectively, the review provided evidence for the effectiveness of exercise alone inlowering the risk of falls, although none of the findings described in the individualstudies21–23 provided evidence for a reduction in fall rates. Sample sizes were alsosmall in each study and poststroke survivors constituted the study sample in onestudy.21 Pooling the results of the 2 multifactorial intervention studies that combinedexercise with environment/assistive technology and education did not significantlylower fall rates or risk of falling in acute and/or subacute settings.24,25 Differences inthe duration of the intervention across studies likely contributed to the nonsignificantfindings. The mean duration of the intervention was only 8 days for patients in acutecare and 17 days for patients in subacute care in the Cumming and colleagues24

study, while the mean duration was 30 days in the study conducted by Haines andcolleagues25 in a subacute care setting. However, it is important that significant differ-ences in fall rates between the intervention and control group did emerge following 45

days of intervention in this latter study. Although more studies need to be conducted in these 2 settings before definitiveconclusions and/or recommendations can be made as to which intervention strategiesare effective, exercise-based interventions are not likely to be effective in lowering fallrates and/or fall risk unless they are of a sufficient duration and intensity. Given the veryshort stay of patients in acute care settings, other intervention strategies are likely to bemore effective in lowering in-hospital fall rates (eg, elevated supervision based on risk,bed alarms). No postdischarge follow-up was included in any of the published studies,so the long-term protective effects of the exercise interventions cannot be ascertained.

Long-Term Care Settings: Stand-Alone Exercise and Multifactorial Approaches As many as 3 out of 4 older adults living in long-term care facilities (eg, nursing homes)fall each year, twice the rate of falls sustained by older adults residing in the commu-nity.26 Approximately 10% to 20% of nursing home falls result in serious injury withfractures constituting 2% to 6% of the injuries reported.27 Statistics such as thesesuggest the need for well-designed fall risk reduction programs that address themultiple risk factors contributing to falls. Central to these fall risk reduction programsis the need for a carefully constructed exercise component, given that muscle weak-ness and walking or gait problems are the most common causes of falls amongnursing home residents.26

Unfortunately, several studies investigating the efficacy of various types of fall riskreduction interventions in this setting have yielded mixed results, as summarized ina recently published Cochrane review.8 A total of 30 studies conducted in long-termcare facilities with high-level,6 intermediate-level,7 or mixed levels of care17 werereviewed. Eleven trials involved supervised exercise only while 4 trials included exer-cise as a component of a multifactorial intervention strategy. The characteristics andfindings of selected intervention trials are presented in Table 2.

Rose & Hernandez610


5/25

Collectively, the findings emerging from those studies that included a single cate-gory of exercise only were disappointing, with no significant reduction in fall rates orfall risk evident when data were pooled across 7 trials. Neither was a significant reduc-tion in the rate or risk of falling evident for 3 trials that included tai chi as the singlemode of exercise.28–30 Of perhaps greater concern was the finding that multimodalexercise interventions (ie, balance/gait, resistance, and/or flexibility) actuallyincreased the rate of falls experienced by the intervention group when pooled datafrom 4 trials were analyzed.29–32 The only types of exercise interventions that positivelyinfluenced fall rates were those that combined balance, gait, and coordination trainingwith mechanically induced perturbations.33,34 These studies included small samplesizes, however, and likely included older adults at higher functional levels based onthe use of a treadmill to conduct the training.

By contrast, multifactorial intervention strategies that included exercise as a corecomponent resulted in a significant reduction in the rate of falling. Multifactorial inter-ventions led by a multidisciplinary team of health professionals as opposed to a singlehealth care professional also proved to be more effective in significantly lowering therisk of falling. Given that the residents of long-term care facilities are frail or transition-ing into frailty and experiencing multiple risk factors for falls, it is perhaps no surprisethat interventions targeting this segment of the older adult population require a multi-factorial approach and multidisciplinary perspective. A closer review of the findings of the individual studies described in Table 2 provides some insight as to the factors thatmay have influenced an intervention’s effectiveness. In general, the ineffective inter-ventions were associated with high dropout rates or poor adherence to the exerciseintervention,30,35 included older adults at very different levels of frailty,29 or lacked

the intensity or duration needed to improve balance to a level likely to result in loweredfall rates and/or risk for falls.36 Faber and colleagues29 divided their groups based onthe number of frailty indicators present. Older adults identified with 3 or more frailtyindicators were categorized as frail whereas those older adults with fewer than 3 indi-cators were categorized as pre-frail. Subsequent subgroup analyses indicated thatmembers of the frail subgroup were more likely to become fallers as the interventionprogressed whereas members of the pre-frail group actually lowered their risk of falling, with risk becoming significantly lower after 11 weeks of training. This findingpoints to the need to carefully target an exercise intervention according to frailty level.Similarly, Rosendahl and colleagues36 demonstrated that only those older adults in the

intervention group who improved their balance demonstrated significantly lower fallrates during the 6-month post-intervention follow-up period. This finding suggeststhat designing an exercise intervention, whether as a stand-alone strategy or asa component of a multifactorial intervention strategy, that is focused on improvingbalance in a standing position is very important.

TRANSLATING RESEARCH INTO PRACTICE: DESIGNING STRUCTURED EXERCISE

PROGRAMS AIMED AT LOWERING FALL INCIDENCE RATES AND FALL RISK

Exercise that addresses the multiple dimensions of balance should be considered the

foundation of any structured exercise program aimed at reducing fall risk. Activitiesdesigned to improve older adults’ ability to process and integrate sensory information,anticipate and/or react quickly and efficiently to changes in the environment, allocateattention appropriately, and perform standing balance and coordination activities ina controlled manner and with minimal support should be considered particularlyimportant components of such a program.37,38 Including whole body functional activ-ities that focus on improving muscular endurance (ie, the ability of a muscle or muscle



6/25

Table 1

Characteristics and findings of interventions conducted in acute and subacute care settings

Study Participants Intervention Type Outcome Measures

Barreca et al, 200421 N 5 48age: 64 y (mean 5 68.5)

35% femaleSetting: stroke rehab unitsRange of stay: 70–90 d

Exercise-only RCTDuration: 4-mo period

Intervention 5 “extra practice”group received daily regularstroke rehabilitation &Sit-to-Stand protocol(45 min session 3 /wk)

Control 5 “conventionalpractice” group receiveddaily stroke rehabilitation &recreational therapy (3 /wk45 min sessions)

Primary: # of falls, sperformance, QO

self-reported phymobility

Cumming et al, 200824 N 5 3999

Age: mean 5 79 ySetting: 12 acute wards & 12

rehabilitation wards in 12hospitals

Mean length of stay: acute 8 d,subacute 17 d

Multifactorial RCT

Duration: 3-mo trials over36 mo

Intervention 5 individuallytailored fall risk assessmenton admission, education, PT1 balance & functionalexercises, alarms as needed

Control 5 usual care

Primary: # falls; freq

falls per patient; fof falls across warinjurious falls; # f


7/25

Donald et al, 200022 N 5 54Age: mean 5 82.7 y78% femaleSetting: elderly care

rehabilitation ward incommunity hospital in UK

Multifactorial RCT:Duration: 3-mo periodIntervention 5 two flooring

types: vinyl or carpet nearbed area combined withseated strength training,group exercise (2 /daily 3 mo) in addition toconventional physiotherapy

Control 5 conventionalphysiotherapy (1–2 daily)

Primary: fall incidenfalls, # of fallers infollow-up period)strength, walk timstrength

Jarvis et al, 200723 N 5 29age: age range & mean not

specified100% femalesetting: subacute elderly care

rehabilitation ward in UK

Exercise-only RCT (pilot study)Duration: 8 wk periodIntervention 5 1 /wk home

physiotherapy treatmentControl5 seen 1 /wk in day

hospital setting or had notreatment

Primary: # of falls pe# of falls, mean # group

Secondary: balanceconfidence, deprewalking, balance,

Haines et al, 200425 N 5 626age: 38 y67% femaleSetting: 3 subacute wards in

a metropolitan hospitalMean length of stay: 30 d

Multifactorial RCTIntervention 5 falls risk alert

card, exercise program (45min individualized sessions3 /wk included tai chi &functional activities),education program, hipprotector

Control 5 usual care

Incidence rate of farelated to falls, & of participants exone or more falls

Abbreviations: CG, control groups; FR, functional reach; IG, intervention group; PT, physical therapy; QOL, qualit

significant.


8/25

Table 2

Characteristics and findings of intervention studies conducted in long-term care settings


Becker, 200373

N 5 981Age: 60 y (mean: 85)70% femaleSetting: 6 long-stay NHsRequired 1–1.5 h of care in

BADLs/d for >6 mo

Multifactorial prospective,cluster RCT

Intervention: education,environmental change,supervised exercise(2 /wk 12 mo, 75 min)

Hip protectorsControl: usual care (wait-list)

Primary: # falls, fall 1000 resident-yea# frequent fallersnonhip fractures

Follow-up: 1 ySecondary: 5-chair s

walk; standing baABOS (subgroup)

Buettner, 200231 N 5 25Age: 60–98 y (mean: 83.3 y)Setting: special care units in 3

NHs. Pts with MMSE 23;multiple falls in past 2 mo

Exercise-only RCTSupervised exercise (walking,

balance, strength, flexibility)

3 /wk 2 moControl: usual care (wait-list)

Primary: # fallsSecondary: upper b

strength; distance

Follow-up: none

Choi et al, 200528 N 5 68Age: 60 y (mean 5 77.84 y)Females: 75%Setting: 2 LTC facilitiesAmbulatory pts with 1 or more

risk factors (impairedbalance/gait previous falls)

Exercise only: Quasi-RCT withnonequivalent control

12-movement Sun style Tai Chi3 /wk 12 wk, 35 minControl: usual care

Primary: # falls; fallsmuscle strength (walking speed & balance

Follow-up: 1 y

Dyer, 200474 N 5 196

Age: 60 y (mean: 87.3 y)Setting: 20 residential care

homes

Cluster-randomized

multifactorial RCTProgressive exercise: bal/gait;

resistance, flexibility,endurance (3 /wk 12–14wk, 40 min), medicationreview, environmentalmodification, vision,podiatry; staff education

Primary: # falls & # r

falls (>3) per persSecondary: # oral m

& # sedatives per Balance & gait (POM

injurious falls (fraFollow-up: 1 y


9/25

Faber et al, 200629 N 5 278Age: 63–98 y (mean 5 85 y)79% femaleSetting: 15 LTC centers51.1% (N 5 120) pre-frail

(N 5 15 of 120 nonfrail);48.9% (N 5 115) frail basedon Fried Frailty Index

Exercise-only multicenter RCTTwo intervention arms:

Functional Walking (FW) orIn Balance (IB)

FW: progressive exercise basedon Otago program; IB:7-movement tai chi sequence.

Control group: Usual care(friendly visits) 1 /wk for4 wk to 2 /wk for 16 wk,90 min

Primary: # falls, # offalls per person ptime to first fall

Secondary: balance (POMA); physicalperformance; selfphysical disability

Follow-up: 52 wk

Jensen et al, 200265 N 5 402Age: 65–100 y

(median 5 83.5 y)72% femaleSetting: 9 residential care

facilitiesPts with physical or cognitive

disability

Multifactorial cluster RCT11 wk intervention: staff

education; environmentalmodifications; supervised 1:1exercise (resistance, bal/gait,transfers) 2–3 /wk 9.1 9.1 wk; supply or repair of

aids; medical review; hipprotectors; post-fall staffmeetings and guidance

Control group: usual care

Primary: # falls per pfalls; time to first

Secondary: # fall-relinjuries

Follow-up: 34 wk

McMurdo et al, 200035 N 5 133Age: mean 84 6.8 ySetting: 9 residential homesMMSE score 12

Multicenter multifactorial RCTIntervention group: fall risk

factor assessment &modification; exercise(seated balance, resistance,flexibility) 2 /wk 6 mo, 30min; vision check; medical

review and follow-up;postural hypotension

Control group: reminiscencesessions (2 /wk 6 mo)

Primary: # falls; # faper person; # fallsperson/wk; # repeperson (>3); # of ffractures per pers

Secondary: FR; RT; Tstrength; spinal fl

QOL; MMSE


10/25

Table 2(continued )


Nowalk et al, 200130 N 5 112Age: 65 y (mean 5 84 y)Setting: 2 LTC facilities70% independent

Exercise-only RCTTwo intervention arms: FIT NB

Free (resistance; endurance,flexibility 3 /wk 2 y);Living & Learning/Tai Chi(FOF intervention: 1 mo/taichi: 3 /wk 2 y)

Control group: basic enhancedprogram; no exercisecomponent

Primary: # falls; timfall; time to deathdays

Secondary: Grip, hipstrength; Chair stamin walk time

Follow-up 21.9 4.

Rosendahl et al, 200836 N 5 191Age: 65(mean 5 84.7 y)Setting: 9 residential care

facilitiesDependent in 1 BADL;

MMSE 12

Exercise only, stratified clusterRCT

Intervention: HIFE program(lower body strength,balance/gait: 5 /every 2 wk 3 mo, 45 min)

Placebo control: seatedactivities (read, sing, watch

TV); no exercise

Primary: # falls per pproportion of fal

Secondary: BBSFollow-up 3 mo

Sakamoto, 200675 N 5 553Age: 37 y (mean 81.6 9.0 y)Setting: special nursing homes;

aged care facilities;outpatient rehab center

High risk for falls; none withsevere dementia

Exercise-only RCTIntervention: one-legged

stance (3 /d 1 min eachleg, EO 6 mo)

Control group: usual activity

Primary: # falls; # offractures sustaine

Follow-up 6 mo posintervention


11/25

Schoenfelder, 200076 N 5 16Age: 65 ySetting: 2 LTC facilities

Exercise-only RCTIntervention: supervised

exercise (anklestrengthening & walking 3 /wk 3 mo, 20 min)

Control: usual care

Primary: # fallsSecondary: balance;

speed; ankle strenfalls efficacy

Shimada et al, 2004

33

N5

32Age: 66–88 y (mean: 82.4 y)78% femaleGeriatric health services facilityHigh-risk pts

Exercise-only RCTIntervention: treadmillwalking with perturbationsplus usual exercise (600 minaccumulated over 6 mo;intensity, duration, &walking speed increased)

Control: usual exercise

Primary: # falls; timeSecondary: OLS; FR;walk; RT while wa

Follow-up 6 mo

Sihvonen et al, 200434 N 5 27Age: 70 y (mean: 81.8 y)100% female

Exercise-only RCTIntervention: “Good Balance”

training using computerizedplatform with visualfeedback 1–3 /wk 4 wk,20–30 min 1:1)

Control: usual activity

Primary: # falls; % operson; relative riinjurious falls

Secondary: balance,Follow-up: 1 y post

Abbreviations: ABOS, altered base of support; BADLs, basic activities of daily living; BBS, Berg Balance Scale; EO, eyActivity Restriction Scale; HIFE, high-intensity functional exercise; MMSE, Mini Mental Status Examination; MMT, Mone-legged stance; PA, physical activity; POMA, performance-oriented performance assessment; pts, patients; RT,


12/25

group to continue contracting repeatedly over multiple repetitions), overall strength (ie,the maximal force a muscle or muscle group can generate at a given velocity), andpower (ie, ability to forcefully contract a muscle or muscle group in a short period of time), particularly in the muscle groups that contribute to postural alignment andstability during gait (eg, ankle, knee, hip, and trunk) are also important for maintaininga high level of physical function.39 Including activities that require performing multipletasks simultaneously (eg, walking while counting backward) will be particularly impor-tant when designing exercise interventions for community-residing older adults.40

Finally, physical activities designed to improve aerobic endurance should also beincluded in any physical activity program aimed at reducing fall risk. In addition tomaking it more difficult to complete tasks of daily living efficiently, poor endurancelevels will also negatively impact attention and lead to heightened fall risk when higherlevels of attention or distribution of attention across tasks is needed.

The Role and Type of Exercise Intervention is Related to the Level of Fall Risk

For older adults at low risk for falls (ie, no history of falls in previous year, absence of known risk factors for falls), physical activity serves a primary role in preventing theonset of disability. Not only does regular participation in physical activity yield impor-tant health and performance-related benefits, but it also can protect older adults fromseveral chronic diseases (eg, heart disease, diabetes, osteoporosis) and the onset of disability by helping them maintain their level of physical capacity above criticalthresholds needed to perform everyday activities independently and efficiently.41

Among older adults at relatively low risk for falls, many physical activity choices areavailable based on interest and skill level. One of the simplest and least resource-

intensive physical activities in which the majority of older adults can participate iswalking. Engaging in a daily walking routine of moderate intensity for at least 30minutes a day will help an older adult maintain adequate levels of strength, aerobicendurance, balance, and coordination. This recommendation is consistent with newlypublished guidelines that recommend that older adults engage in 30 minutes of moderate-intensity activity 5 or more days per week or 20 minutes of vigorous-inten-sity activity 3 or more days per week to derive important health benefits.2 Walking hasalso been identified as the physical activity of choice among ethnically diverse olderadults, and may therefore serve as an important basis on which to build fall risk reduc-tion programs aimed at culturally diverse groups of older adults.42

Balance can be effectively challenged during a walking program by manipulatingboth the environmental and task demands associated with the activity. For example,incorporating walking activities on different surfaces (eg, grass, sand, chip, or barktrails), with varied elevations, or using walking poles can elevate the level of cardiore-spiratory and caloric expenditure but without significantly increasing perceived exer-tion.43,44 Older adults who are less stable when walking or fearful of falling may alsobenefit, if sufficiently coordinated, from the use of walking poles to improve their over-all level of stability. Incorporating different gait patterns (eg, longer strides, narrowwalking, zig-zag walking) and/or variations in gait speeds and walking terrain (eg, hills,trails, sand) can also add variety to the walking routine while also targeting balance,

strength, and coordination.Participating in multiple component group exercise classes that include balance,

muscular strength, endurance and power, aerobic endurance, and flexibility activitieshave also been shown to be effective in reducing important physical risk factors asso-ciated with falls in relatively healthy groups of older adults.45 In addition, group-basedclasses provide a socially supportive activity environment and a level of supervision andstructure that many older adults need to engage over the long term. Other recreational

Rose & Hernandez618


13/25

activities that incorporate many of the important functional parameters listed includetennis, golf (combined with walking versus riding around the course), bicycle riding,and different types of dancing to music (eg, ballroom, line dancing, tango).

Research findings also support tai chi as an effective means of reducing fall inci-dence rates among community-residing older adults.46,47 The delivery of tai chiprograms in community settings has several advantages. Tai chi requires no equip-ment, can be performed indoors or outdoors, and can be performed in a group or indi-vidually in the home. Although easy to initiate in community-based settings, however,programming must give careful consideration to the form of tai chi selected and thequalifications of the instructor hired to lead the class. The Li and colleagues46 studyselected the Yang style of tai chi and reduced it to 24 different movements thatemphasized multidirectional weight-shifting, multisegmental (arms, trunk, legs) coor-dinative movements, awareness of body alignment, and synchronized breathing.The Li program has been further reduced to an 8-sequence program and is beingnationally disseminated as the Tai Chi: Moving for Better Balance program.48 Whetherthis modified version of the program proves to be as effective in reducing fall rates andfall risk to the extent of the original 24-sequence program evaluated in a controlledsetting has yet to be determined.

For older adults identified at moderate risk for falls (ie, history of 1–2 falls in previousyear, presence of one or more known risk factors for falls, including comorbid medicalconditions), physical activity serves a secondary role by slowing the progression of disease and/or system impairments that limit an older adult’s ability to performmany daily activities independently. The research described earlier suggests thatthis group of older adults will derive more benefit from participating in physical activity

programs that systematically target the identified physical risk factors duringa comprehensive fall risk assessment. At this level of risk, programs need to bemore tailored to the individual needs of participants and incorporate specific balanceand gait activities, coupled with functional activities designed to improve muscularstrength, endurance, and power. Activities should specifically focus on improvingdynamic postural control in changing sensory environments and while performingweight shifting, and transfer tasks of increasing complexity and preferably whilestanding with minimal upper body support. Just as the principle of overload (ie,exposing a tissue or organ to a load to which it is not normally accustomed to improveits function)49 applies when exercising the cardiovascular and musculoskeletal

systems, it is just as important to systematically and progressively challenge an indi-vidual’s balance abilities. Preliminary evidence also suggests that performing increas-ingly challenging balance activities in dual-task environments (eg, balancing orwalking while performing a second task) is also likely to have a positive influence onessential cognitive processes (eg, attention, memory, problem solving).40 Observableimprovements in balance and mobility also positively influence the individual’s situa-tion-specific self-confidence level as well as the more global fear of falling. Whetherthis type of program is implemented with community-residing older adults ina group-structured setting or as a home-exercise program does not appear to influ-ence the outcomes.7 A significant reduction in fall risk and/or fall incidence rates

has been shown in both types of settings.Individually tailored exercise programs that target known intrinsic risk factors also

appear to be most effective for frail older adults who are advanced in age (>80 years)and/or at high risk for falls (ie, injury-related fall within past 6 months, presence of 2 ormore risk factors associated with falls, including comorbid conditions that are lessmedically stable). A health care professional or specifically trained professionalswho can tailor the type of exercise to the specific needs and abilities of the individual



14/25

are best suited to leading these types of programs. The initial focus in these types of exercise programs should be on strengthening all major muscle groups in a seated orsupported standing position until sufficient strength permits the inclusion of minimalsupport or unsupported standing exercises that emphasize dynamic balance andmobility. In addition to the improvements in physical capacity gained, these programsalso positively affect the individual’s perceived quality of life. For older adults at highrisk for falls, physical activity serves a tertiary role by raising their physical capacity toa level that will allow for greater independence in the performance of essential activ-ities of daily living (ie, dressing, bathing, transfers) and require less assistance withmore advanced activities of daily living (eg, shopping, walking in the community,assorted household chores).

Just as the type of exercise prescribed changes as the level of fall risk increases, sotoo does the intensity of the intervention strategy needed. In addition to a carefullytailored exercise program, older adults identified at high risk for falls appear to derivegreater benefit from a multifactorial intervention strategy that begins with a compre-hensive medical screening for the purpose of identifying the specific fall risk factorscontributing to each individual’s heightened fall risk. Subsequent intervention strate-gies should then be based on the results of the initial screening and may include treat-ment of chronic medical conditions, an individualized exercise program, medicationreviews, vision assessment, training in assistive device use, home assessment andmodification, and fall risk education aimed at changing behavior.7,8 Although multifac-torial intervention strategies have the potential to be more resource intensive and time-consuming for the recipient, careful prioritizing and/or staging of the intervention mayreduce some of the confusion and resistance that Campbell and Robertson50 argue

make them no more effective than single-strategy approaches. Gates andcolleagues51 further suggest that multifactorial interventions that “provide treatmentsto address risk factors rather than information and referral may be moreeffective.”51( p132)

FUTURE RESEARCH DIRECTIONS

The optimal type, intensity, frequency, duration, and progression of exercise neededto significantly lower fall risk over the long-term are still not known. There are 7 issues,relating to either the design and conduct of physical activity–based research or fall risk

reduction research in general, that remain to be answered:

Is There One Type of Exercise Intervention that is Most Effective in Lowering Fall Risk and Fall Incidence Rates?

No definitive evidence currently exists to support one type of exercise interventionmore than another, although the recent Cochrane review7 provides evidence for theeffectiveness of interventions that provide multiple categories of exercise, whetherdelivered in a group setting or individually prescribed in the home. Tai chi has alsobeen shown to be an effective exercise intervention when delivered to community-residing older adults. It has not been shown, however, to be an effective intervention

strategy when the recipients are more frail older adults or transitioning into frailty.8Based on a systematic review of 44 exercise interventions aimed at reducing fall inci-dence rates among community-residing older adults, Sherrington and colleagues52

recommended that exercise interventions include progressively challenging balanceexercises that are performed while standing and with minimal upper body support.It is further recommended that a minimum of 50 hours of exercise (twice weekly 1-hour program for 25 weeks) is needed before fall incidence rates are lowered

Rose & Hernandez620


15/25

significantly. Those exercise programs that did not include a walking component werealso more effective in reducing fall rates. The investigators advanced two alternativeexplanations for this finding: including walking exposed participants to greater riskfor falling; and time was better spent engaging in focused balance training versuswalking when the program was of a limited duration. Perhaps a more important ques-tion to address is who is likely to benefit more from a particular type of exercise inter-vention. Is it the older adult at a higher or lower level of fall risk? Certainly in the case of exercise interventions that include multiple categories of exercise, fall rates can belowered whether the older adults are at a higher or lower risk for falls at baseline.7

Sherrington and colleagues52 further suggest that the absolute effects of exercisemay be greater for older adults at higher risk for falls.

How is age, gender, and/or ethnic background of the participant likely to influencewhich type of exercise intervention is selected and/or its outcomes? Here again, theavailable evidence is limited. In one of few instances where individual-level data wereretrospectively analyzed, Robertson and colleagues53 concluded that the older (andlikely more frail) participants in their series of studies derived greater benefits (ie, lowerfall incidence rates) than the younger study participants. Similarly, Clemson andcolleagues54 found that their community-based program benefited men more thanwomen when selected subgroup analyses were conducted. Given how difficult it is toengage men in fall risk reduction activities, this finding has important practical implica-tions for program design. The fact that very few published studies have includeda diverse older adult population or a sufficient number of ethnically diverse older adultsin the sample make it difficult to conduct subgroup analyses across ethnic groups.

Should the Level of Fall Risk Influence the Type and Intensity of InterventionStrategy Prescribed?

Although multifactorial fall risk assessment and intervention strategies have beenshown to have the greatest effect in reducing fall rates and fall-related injuries in olderadults with a history of falls, more research is needed to determine the best combina-tion of intervention strategies as well as the extent to which each individual componentcontributes to the total reduction in fall risk. It has recently been suggested by Camp-bell and Robertson,50 after comparing the outcomes of single and multifactorial inter-ventions, that although multifactorial intervention strategies may be appropriate forindividual patients, “there is no direct trial evidence that multiple or multifactorial inter-

ventions are more effective than targeted single interventions for community popula-tions at risk.”50(p657) Instead, the investigators argue that well-designed single-factorintervention programs (that may or may not include exercise) delivered to carefullyselected populations may prove as effective as multifactorial programs in fosteringlong-term participation and reducing fall incidence rates in at-risk groups. Campbelland Robertson further contend that targeted single interventions may be more accept-able and cost-effective for these same risk groups because they cause less confusion,require the older adults to make fewer changes in their lives, and are simply less time-and resource-intensive.

How Does the Reporting of Study Outcomes Influence the Perceived Effectivenessof Exercise Interventions in Reducing Fall Risk?

It is often difficult to compare the outcomes of research studies because of the incon-sistency with which fall-related outcomes are both monitored and reported, in part dueto the varying definitions of falls used across studies. Whereas some studies usebroader definitions that include slips and trips,55 other studies have adopted morestringent criteria.54,56,57 Given that fall incidence rates often serve as the primary



16/25

outcome of interest in many studies, it is critical that a standardized definition be adop-ted so that the results of the different intervention strategies tested can be bettercompared and meaningful clinical guidelines related to fall prevention developed. Itis also important that what constitutes a fall is clearly conveyed to the study participantso that falls are accurately recorded. Zecevic and colleagues58 have previously shownthat the perceptions of older adults vary widely if a clear fall definition is not provided tothem. In an effort to address this lack of standardization, ProFaNE (Prevention of FallsNetwork Europe) recently published a consensus statement of outcome definitionsthat included one to describe a fall. This consensus group recommends adoption of the following definition of a fall: “an unexpected event in which the participant comesto rest on the ground, floor, or lower level.”10(p1619)

Compounding the lack of consensus on what constitutes a fall is the lack of stan-dardization relative to the methods used to monitor fall occurrences, the types of fall outcomes used to compare group differences, and the length of time over whichfalls are monitored in any given investigation. Whereas some studies rely on retro-spective self-reports of falls, others use fall diaries in which falls (and other relevantinformation related to the fall) are recorded on a daily basis sometimes before andduring an intervention and/or for a predetermined period of time following the conclu-sion of the intervention. A wide range of fall outcomes (eg, number of single and/orrecurrent fallers, fall rates, fall-related injuries, time to first fall) are often reportedacross studies, once again making it difficult to compare the relative benefits of different intervention strategies. Postintervention fall-monitoring periods in commu-nity-based studies have ranged from as little as 2 months to 2 years, making it difficultto equate the extent of the benefits derived from one physical activity intervention

strategy with another.59

In some cases, fall incidence rates have only been reportedfor the duration of the intervention itself, with no postintervention follow-up periodincluded.8 Until such time as investigators adopt a universal definition of what consti-tutes a fall, near-fall, slip, or trip, and a consistent method for reporting outcomesacross a uniform time frame, it will not be possible to accurately determine whichtype of intervention, irrespective of whether it includes exercise, is superior to anotherin reducing the incidence of falls. Gates and colleagues,51 in a recent review of multi-factorial approaches to fall risk reduction, contend that the more important falloutcomes to report are fall injury and fracture rates because they have the greatestimpact on the individual’s health and use of resources. How falls are treated in

different statistical models (ie, as recurrent or nonrecurrent events) also need to beconsidered based on the goals of the intervention being implemented. For example,Skelton,60 in a recent opinion piece published in the ProFaNE Community Onlinenewsletter, suggested that the amount and type of fall information collected andanalyzed may differ based on whether the goal of the intervention is to prevent the“first fall” or lower the rate of falls and/or injuries sustained. For example, in thecase of older adults identified at low levels of fall risk, the major goal of any interventionshould be to prevent the first fall and maximize function whereas when designing andimplementing interventions for frail older adults who are at high risk for falls andalready falling, the primary goal should be fall management by reducing the rate at

which falls and/or injuries occur.

Should a Reduction in Falls Constitute the Only Outcome Used to Judge an

Intervention’s Effectiveness?

The effectiveness of any exercise intervention should not solely rest on whether fallincidence rates are appreciably lowered in the targeted group. Given that the bestresearch outcomes have lowered fall risk or fall incidence rates no more than

Rose & Hernandez622


17/25

50% in groups completing an exercise intervention, does that mean that the remain-ing 50% achieved less than satisfactory outcomes? Judgment concerning an inter-vention’s effectiveness should consider additional outcome measures such as theuse of health care services; improvements in the overall level of disability or func-tion, and psychosocial measures such as fear of falling, depression, and perceivedquality of life. Given that a successful exercise intervention likely leads to higherlevels of physical activity, it would not be surprising if the intervention increasesthe risk for falls due to increased exposure to environmental hazards. To recognizethis potentially offsetting phenomenon, fall incidence rates should be adjusted forphysical activity levels during a postintervention follow-up period.61 At the very least,physical activity levels should be monitored during the postintervention follow-upperiod to evaluate whether the particular exercise intervention was effective inchanging the individual’s exercise behavior.

The need to include other outcomes is particularly important when evaluating theeffectiveness of exercise interventions conducted with more frail older adults.

Although the majority of studies reviewed by Cameron and colleagues8 were noteffective in reducing fall rates, significant improvements were evident for othermeasures such as balance and gait, strength, falls efficacy, and reaction time (seeTable 2 ). As stated earlier, the tertiary role of physical activity for those older adultswho have reached a level of system impairment or disease progression that can nolonger be slowed lies in the restoration of function to a level that allows for as muchautonomy as possible in the performance of basic daily activities. Unfortunately, nostudies reviewed by Cameron and colleagues8 examined whether the performanceof basic activities of daily living were improved as a result of the exercise interven-

tion. Future studies should consider including measures that evaluate improvementsin this area.

Are Fall Risk Reduction Programs, Irrespective of Type, Cost-Effective or Cost-Saving?

To date, few studies have demonstrated the cost-effectiveness associated witha given intervention strategy. Rizzo and colleagues18 calculated the mean cost perolder adult who received the targeted intervention during the Yale FICSIT trial33 atUS$925 (based on 1996 costs) while Robertson and colleagues62 calculated thecost per person of delivering the Otago home-exercise program per year to be NZ$418 (based on 1998 prices). Cost savings were also shown in reduced fall-related

hospital admissions for the same home-based exercise intervention.62 Moreover,Tinetti and colleagues19 stated that the 11% reduction in the use of fall-relatedmedical services noted in their very large regional study in Connecticut “representsa potential savings of $21 million in health care costs on the basis of an average acutecare cost of $12,000 per event.”19( p260)

An economic evaluation was also conducted as part of the 2009 Cochrane Reviewthat assessed the effectiveness of interventions aimed at reducing falls amongcommunity-residing older adults.7 Some evidence was provided that certain interven-tion strategies can be cost-effective and/or cost-saving. Specific to the exercise inter-ventions reviewed, additional evidence was provided for the cost-effectiveness of

a 16-week tai chi class47 as well as the other interventions reviewed here. Althoughmore evidence is needed to support the cost-effectiveness and/costs savings associ-ated with fall risk reduction programming, given the average health care costs asso-ciated with a fall injury have been calculated to be as high as US$19,440 (includingemergency room, hospital, nursing home, and home health care, but not physicians’services)63 it is not likely to be too difficult to demonstrate that programs designed toreduce falls are at least cost-effective, if not also cost-saving.



18/25

How Do the Factors of Ethnicity, Socioeconomic Status, and Geographic Location

Affect the Type of Intervention Strategy Prescribed?

Little if any research to date has examined the effectiveness and acceptability of physical activity or more structured exercise programs, or any other fall risk reduc-

tion strategy, for reducing falls among older adult groups who are ethnically diverse,of different socioeconomic status, and/or geographically isolated. Future researchshould focus on how best to develop and implement fall risk reduction programsaimed at reducing falls among ethnically diverse and socioeconomically disadvan-taged groups of older adults. Each of these variables may pose important barriersto implementation and therefore deserve immediate attention. Recently conductedfocus group research makes it clear that cultural background influences olderadults’ perception of what is an acceptable type and frequency of physicalactivity.42 Location of residence (urban versus rural) and sufficiency of economicresources to gain access to available programs also will likely shape both the

content of fall risk reduction interventions and how they are delivered to the targetpopulation.

Are Fall Risk Reduction Programs Effective in Lowering Falls Among Older AdultsWho are Cognitively Impaired?

The majority of studies providing support for the inclusion of exercise as an effectiveintervention strategy have primarily targeted community-residing older adults withnormal or only very mildly impaired cognition. Much less evidence currently existsfor the role of exercise as either a stand-alone or integrated component of a multifac-torial intervention strategy aimed at reducing falls and/or fall risk among older adults

who have been diagnosed with dementia. The results of an exploratory analysis con-ducted in the recent Cochrane review by Cameron and colleagues8 on data pooledfrom 2 studies that included participants with cognitive impairment64,65 indicated nosignificant differences in the risk of falling demonstrated between the 2 studies.Jensen and colleagues65,66 compared fall rates for intervention participants witha Mini Mental State Examination (MMSE) score of less than versus greater than 19,and found a significant reduction in fall rates for the less cognitively impaired grouponly. Of interest was the finding that fracture rates were significantly lower for the inter-vention subgroup with the MMSE score of less than 19 when compared with thecontrol subgroup with an MMSE score lower than 19. Designing a fall risk reduction

program for older adults with cognitive impairment that includes physical activity/exer-cise will also require careful thought to minimize the likelihood of adverse events andmaximize adherence over the long term. Given that individuals with cognitive impair-ment are twice as likely to fall as their cognitively intact peers,67 this future line of research should receive high priority.

What Type(s) of Intervention Strategies Are Effective in Promoting Long-TermParticipation in Physical Activity and Related Fall Prevention Activities?

Engaging in fall prevention activities, including regular physical activity beyond thelength of a given intervention period, is critical for maintaining improvements in phys-

ical capacity and fall risk. Although the research evidence supports the short-term effi-cacy of physical activity interventions in general, the long-term findings are mixed.68,69

To achieve long-term benefits, fall risk reduction programs must be designed in sucha way that older adults are motivated to join and then maintain their participation inphysical activity and other related fall prevention activities (eg, modifying home andimmediate environment for added safety, getting regular vision checkups, eliminatingrisky behaviors) even after the program has ended.

Rose & Hernandez624


19/25

To date, very little fall risk reduction research has systematically included anystrategies designed to effect long-term changes in behavior that will ensure long-term compliance with the fall prevention activities and/or the adoption of protectivebehaviors.54,56 Only a very small proportion of the participants initially screened andrecruited for large-scale randomized controlled trials actually begin the study andfewer still complete the intervention and postintervention follow-up period. Whilemany participants are excluded because they do not meet the study’s initial inclu-sion criteria, or are forced to withdraw because of factors not within their control,a high proportion of eligible participants withdraw from the study at various pointsbecause of lack of interest or motivation to continue participating. Designing morerandomized controlled trials that systematically incorporate strategies for improvingself-efficacy and encouraging behavior change will be particularly important for opti-mizing the older adult’s long-term adherence to the physical activity component of any fall risk reduction program. In recognition of this issue and the need to increasethe level of uptake and long-term involvement in fall prevention activities ata community level, ProFaNE has developed 6 recommendations based on multiplestudies that solicited the views of older adults in regard of fall prevention interven-tions.70,71 In general, the recommendations focus on promoting the specific benefitsof an intervention relative to improving balance and reducing fall risk, fostering self-management skills by having the participant take an active rather than passive rolein the intervention process, matching the intervention to the needs, preferences, andcapabilities of the older adult, and marketing the benefits of the program in a mannerthat is highly valued by older adults (eg, increased independence, improved confi-dence in functional abilities, and a proactive approach to managing their own

health).72

SUMMARY

Despite the many questions and/or issues that need to be addressed in futureresearch, what can be concluded with some level of confidence from the researchpublished to date is that exercise programs aimed at reducing falls at all risk levelsshould include activities that specifically address the physical risk factors associatedwith falls and at a level of intensity that matches older adults’ physical capabilities.While a variety of different activity options are available to older adults at relatively

low risk for falls, as the level of fall risk increases, both the type and intensity of phys-ical activities selected must specifically address the impairments identified, be care-fully tailored to the individual’s physical capabilities, and be progressed accordingly.Stand-alone exercise interventions have not been shown to be effective in loweringfall rates among older adults until at least 50 hours of training has been completed.Of course, a higher total dose of exercise is likely to be needed as the level of fallrisk continues to increase. Including balance activities that are challenging, are per-formed with an altered base of support, require controlled movements of the centerof mass, and are performed in a full weight-bearing position with minimal supportalso produce better fall-related outcomes.40 A staged approach, as recommended

by Baker and colleagues,20 may also be appropriate in the case of multiple physicalrisk factors being identified.

As demonstrated in the recent Cochrane review,7 whether tailored exerciseprograms are implemented in group-based community settings or in the individual’sown home does not seem to affect the outcomes relative to lowering fall rates orfall risk. Good evidence now exists for the use of other forms of exercise such as taichi as a medium for lowering fall risk among more sedentary community-residing older



20/25

adults who are relatively healthy. Programs incorporating more simplified forms of taichi and a smaller number of movement sequences that emphasize the types of move-ments most affected by the aging process appear to be particularly effective inreducing falls. Interest in studying the benefits of other martial arts such as taekwon do53 on balance, gait, and fall risk in community-residing groups has alsoemerged in recent years. A greater variety of activity-based interventions shown aseffective in reducing falls should provide more opportunities for older adults to engagein fall prevention activities.

Unfortunately, the recommendations are less clear when designing stand-alone orintegrated exercise interventions in acute, subacute, and long-term care settings.Given the very short stays in acute settings, it is likely that other fall risk reductionstrategies will be more effective in reducing fall rates and/or fall risk (eg, bed alarms,higher level of supervision, toileting schedules). In subacute settings, however,where the stays are longer, carefully designed exercise interventions that arecombined with other fall risk reduction strategies (eg, individually tailored fall riskassessments on admission, fall risk alert cards, hip protectors) and that are con-ducted over a longer period of time (>3 weeks) appear to be effective in reducingfall rates and/or fall risk.9

Finally, in long-term care settings, the evidence supports the use of multifactorialprograms that target multiple individual risk factors and that are delivered by a multi-disciplinary team.9 Due to the fact that multiple risk factors are contributing to thegreatly heightened fall risk evident among frail older adults, exercise alone is unlikelyto be effective in lowering risk among this segment of the older adult population. Thesuitability of frail nursing home residents for inclusion in exercise-based interventions

should also be carefully assessed. In these settings, preexisting criteria for evaluatingfrailty levels (eg, Fried Frailty Index) should be used to select those older adults mostlikely to benefit from the intervention. There is some evidence to suggest that olderadults who have not yet transitioned into frailty will benefit more from an exercise-based program than their more frail peers.29

In conclusion, a review of the existing research demonstrates that carefullydesigned and progressive exercise programs play an important role in preventing fallsand/or lowering an older adult’s risk for falling across multiple settings. For healthyolder adults at low risk for falls, engaging in a broad range of physical activitiesdesigned to improve aerobic endurance, strength, and balance on a regular basis is

likely to be sufficient to substantially reduce the risk for falling. By contrast, olderadults at moderate risk for falls may benefit more from engaging in structured exerciseprograms that systematically target the physical risk factors amenable to change andare progressed at a rate that is determined by the individual’s capabilities and previousexperience with physical activity. Older adults identified at high risk for falls are likely tobenefit more from an individually tailored exercise program that may or may not beembedded within a larger, multifactorial intervention approach, depending on whichrisk factor or factors are determined to be the major contributors to an individual’sfall risk. Determining whether a single or multifactorial intervention approach is indi-cated will first require that a comprehensive assessment of risk is undertaken. Finally,

because long-term adherence to any type of exercise program is critical for long-termreduction in fall risk, designing physical activity/exercise programs that appeal to olderadults from diverse cultural and socioeconomic backgrounds will be important.Including a behavioral counseling component in any exercise program will also be crit-ical so that older adults can develop the necessary self-regulation (eg, goal setting)and self-monitoring of progress skills needed to make physical activity a regularpart of their daily lives.

Rose & Hernandez626


21/25

REFERENCES

1. Rikli RE, Jones CJ. Functional fitness normative scores for community-residing

adults, ages 60-94. J Aging Phys Act 1999;6:160–79.

2. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older

adults: recommendation from the American College of Sports Medicine and theAmerican Heart Association. Med Sci Sports Exerc 2007;39:1435–45.

3. Kramer AF, Erickson KI. Effects of physical activity on cognition, well-being, and

brain: human interventions. Alzheimers Dement 2007;3(2):S45–51.

4. Pope AM, Tarlov AR. Disability in America: toward a national agenda for preven-

tion. Washington, D.C: National Academics Press; 1991.

5. Miller ME, Rejeski WJ, Reboussin BA, et al. Physical activity, functional limitations,

and disability in older adults. J Am Geriatr Soc 2000;48:1264–72.

6. Lord SR. Fall prevention in Australia—current research and knowledge translation

initiatives. Paper presented at the Canadian Fall Prevention Conference: trans-

forming knowledge to action. Vancouver, BC, 2010.7. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls

in older people living in the community. Cochrane Database Syst Rev 2009;2:

CD007146.

8. Cameron I, Murray GR, Gillespie LD, et al. Interventions for preventing falls in

older people in residential care facilities and hospitals (Protocol). Cochrane Data-

base Syst Rev 2005;3:CD005465.

9. Province M, Hadley EC, Hornbrook MC. The effects of exercise on falls in elderly

patients: a preplanned meta-analysis of the FICSIT trials. JAMA 1995;273:1341–7.

10. Lamb SE, Jorstad-Stein EC, Hauer K, et al. Prevention of Falls Network Europe

and Outcomes Consensus Group. Development of a common outcome dataset for fall injury prevention trials: the Prevention of Falls Network Europe

consensus. J Am Geriatr Soc 2005;53(9):1618–22.

11. Campbell AJ, Robertson MC, La Grow SJ, et al. Randomised controlled trial of

prevention of falls in people aged > or 5 75 with severe visual impairment: the

VIP trial. BMJ 2005;331(7520):817. DOI: 10.1136/bmj.38601.447731.55.

12. Ashburn A, Fazakarley L, Ballinger C, et al. Randomised controlled trial of

a home-based exercise programme to reduce fall frequency among people

with Parkinson’s disease (PD). J Neurol Neurosurg Psychiatr 2007;78(7):678–84.

13. Green J, Forster A, Bogle S, et al. Physiotherapy for patients with mobility prob-

lems more than 1 year after stroke: a randomised controlled trial. Lancet 2002;

359(9302):199–203.

14. Sherrington C, Lord SR, Herbert RD. A randomized controlled trial of weight-

bearing versus non-weight-bearing exercise for improving physical ability after

usual care for hip fracture. Arch Phys Med Rehabil 2004;85(5):710–6, 15.

15. Campbell AJ, Robertson MC. Implementation of multifactorial interventions for fall

and fracture prevention. Age Ageing 2006;35(S2):ii60–4.

16. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for preventing falls in

older adults: systematic review and meta-analysis of randomized clinical trials.

BMJ 2004;328:680–7.

17. Tinetti MD, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the

risk of falling among elderly older people living in the community. N Engl J Med

1994;331(13):821–69.

18. Rizzo JA, Baker DI, McAvay G, et al. The cost-effectiveness of a multifactorial tar-

geted prevention program for falls among community elderly persons. Med Care

1996;34(9):954–69.



22/25

19. Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing

injuries from falls. N Engl J Med 2008;359:252–61.

20. Baker DI, Gottschalk M, Bianco LM. Step by step: integrating evidence-

based fall-risk management into senior centers. Gerontologist 2007;47(4):

548–54.

21. Barreca S, Sigouin CS, Lambert C, et al. Effects of extra training on the ability of

stroke survivors to perform an independent sit-to-stand: a randomized controlled

trial. J Geriatr Phys Ther 2004;27(2):59–68.

22. Donald IP, Pitt K, Armstrong E, et al. Preventing falls on an elderly care rehabili-

tation ward. Clin Rehabil 2000;14(2):178–85.

23. Jarvis N, Kerr K, Mockett S. Pilot study to explore the feasibility of a randomised

controlled trial to determine the dose effect of physiotherapy on patients admitted

to hospital following a fall. Pract Evidence 2007;2(2):4–12.

24. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomised trial of a targeted

multifactorial intervention to prevent falls among older people in hospital. BMJ

2008;336(7647):758–60.

25. Haines TP, Bennell KL, Osborne RH, et al. Effectiveness of targeted falls preven-

tion programme in subacute hospital setting: randomised controlled trial. BMJ

2004;328(7441):676–9.

26. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern

Med 1994;121:442–51, 2.

27. Rubenstein LZ, Robbins AS, Schulman BL, et al. Falls and instability in the elderly.

J Am Geriatr Soc 1988;36:266–78.

28. Choi JH, Moon JS, Song R. Effects of Sun-style Tai Chi exercise on physical

fitness and fall prevention in fall-prone older adults. J Adv Nurs 2005;51(2):150–7.29. Faber MJ, Bosscher RJ, Chin A, et al. Effects of exercise programs on falls and

mobility in frail and pre-frail older adults: a multicenter randomized controlled

trial. Arch Phys Med Rehabil 2006;87(7):885–96.

30. Nowalk MP, Prendergast JM, Bayles CM, et al. A randomized trial of exercise

programs among older individuals living in two long-term care facilities: the Falls-

FREE program. J Am Geriatr Soc 2001;49(7):859–65.

31. Buettner LL. Focus on caregiving. Falls prevention in dementia populations.

Provider 2002;28(2):41–3.

32. Toulotte C, Fabre C, Dangremont B, et al. Effects of physical training on the phys-

ical capacity of frail, demented patients with a history of falling: a randomisedcontrolled trial. Age Ageing 2003;32(1):67–73.

33. Shimada H, Obuchi S, Furuna T, et al. New intervention program for preventing

falls among frail elderly people: the effects of perturbed walking exercise using

a bilateral separated treadmill. Am J Phys Med Rehabil 2004;83(7):493–9.

34. Sihvonen S, Sipila S, Taskinen S, et al. Fall incidence in frail older women after

individualized visual feedback-based balance training. Gerontology 2004;50:

411–6.

35. McMurdo ME, Millar AM, Daly F. A randomized controlled trial of fall prevention

strategies in old peoples’ homes. Gerontology 2000;46(2):83–7.

36. Rosendahl E, Gustafson Y, Nordin E, et al. A randomized controlled trial of fallprevention by a high- intensity functional exercise program for older people living

in residential care facilities. Aging Clin Exp Res 2008;20(1):67–75.

37. Rose DJ. Fallproof. A comprehensive balance and mobility program. 2nd edition.

Champaign (IL): Human Kinetics; 2010.

38. Skelton DA, Beyer N. Exercise and injury prevention in older people. Scand J

Med Sci Sports 2003;13:77–85.

Rose & Hernandez628


23/25

39. Kramer WJ, French DN. Resistance training. In: Jones CJ, Rose DJ, editors.

Physical activity instruction of older adults. Champaign (IL): Human Kinetics;

2005. p. 175–90.

40. Silsupadol P, Siu KC, Shumway-Cook A, et al. Training of balance under single-

and dual-task conditions in older adults with balance impairment. Phys Ther

2006;86:269–81.

41. Jones CJ, Rose DJ. The field of gerokinesiology. In: Jones CJ, Rose DJ, editors.

Physical activity instruction of older adults. Champaign (IL): Human Kinetics;

2005. p. 3–10.

42. Belza B, Walwick J, Shiu-Thornton S, et al. Older adult perspectives on physical

activity and exercise: voices from multiple cultures. Prev Chronic Dis 2004.

Available at: http://www.cdc.gov/ped/issues/2004/oct/04_0028.htm. Accessed

February 12, 2010.

43. Rodgers CD, VanHeest JL, Schachter CL. Energy expenditure during submax-

imal walking with exerstriders. Med Sci Sports Exerc 1995;16:607–11.

44. Church TS, Earnest CP, Morss GM. Field testing of physiological responses asso-

ciated with Nordic walking. Res Q Exerc Sport 2002;73:296–300.

45. Wallace JI, Buchner DM, Grothaus L, et al. Implementation and effectiveness of

a community-based health promotion program. J Gerontol A Biol Sci Med Sci

1998;53(4):M301–6.

46. Li F, Harmer P, Fisher KJ, et al. Tai chi and fall reductions in older adults:

a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2005;60:

187–94.

47. Voukelatos A, Cumming RG, Lord SR, et al. A randomized, controlled trial of tai

chi for the prevention of falls: the central Sydney tai chi trial. J Am Geriatr Soc2007;55(8):1185–91, 31.

48. Li F, Harmer P, Glasgow R, et al. Translation of an effective tai chi intervention into

a community-based falls-prevention program. Am J Public Health 2008;98(7):

1195–8.

49. Gillis DE, Stewart AL. A new approach to designing exercise programs for older

adults. In: Jones CJ, Rose DJ, editors. Physical activity instruction of older adults.

Champaign (IL): Human Kinetics; 2005. p. 131–40.

50. Campbell AJ, Robertson MC. Rethinking individual and community fall prevention

strategies: a meta-regression comparing single and multifactorial interventions.

Age Ageing 2007;36:656–62.51. Gates S, Fisher JD, Cooke MW, et al. Multifactorial assessment and targeted

intervention for preventing falls and injuries among older people in community

and emergency care settings: systematic review and meta-analysis. BMJ 2008;

336:130–3.

52. Sherrington C, Whitney JC, Lord SR, et al. Effective exercise for the prevention of

falls: a systematic review. J Am Geriatr Soc 2008;56:2234–43.

53. Robertson MC, Campbell AJ, Gardner MM, et al. Preventing injuries in older

people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr

Soc 2002;50:905–11.

54. Clemson L, Cumming RG, Kendig H, et al. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized

trial. J Am Geriatr Soc 2004;52:1487–94.

55. Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in older persons:

an investigation of Tai Chi and computerized balance training. Atlanta FICSIT

Group. Frailty and injuries: cooperative studies of intervention techniques.

J Am Geriatr Soc 1996;44:489–97.


http://www.cdc.gov/ped/issues/2004/oct/04_0028.htmhttp://www.cdc.gov/ped/issues/2004/oct/04_0028.htm


24/25

56. Campbell AJ, Robertson MC, Gardner MM, et al. Randomised controlled trial of

a general practice programme of home based exercise to prevent falls in elderly

women. BMJ 1997;315:1065–9, 22.

57. Skelton D, Dinan S, Campbell M, et al. Tailored group exercise (Falls Manage-

ment Exercise-FaME) reduces falls in community-dwelling older frequent fallers

(an RCT). Age Ageing 2005;34:636–9.

58. Zecevic AA, Salmoni AW, Speechley M, et al. Defining a fall and reasons for

falling: comparisons among the views of seniors, health care providers, and

the research literature. Gerontologist 2006;46:367–76.

59. Howe TE, Rochester L, Jackson A, et al. Exercise for improving balance in older

people. Cochrane Database Syst Rev 2007;4:CD004963.

60. Skelton DA. Opinion piece: are we using the correct statistics to determine if falls

prevention trials work? ProFaNE community online. Circulation 2009;3470. Avail-

able at: http//www.profane.eu.org/news.php. Accessed July 10, 2010.

61. Rubenstein LZ, Josephson KR, Trueblood PR, et al. Effects of a group exercise

program on strength, mobility, and falls among fall-prone elderly men.

J Gerontol A Biol Sci Med Sci 2000;55(6):M317–21.

62. Robertson MC, Devlin N, Gardner MM, et al. Effectiveness and economic evalu-

ation of a nurse delivered home exercise programme to prevent falls. 1: random-

ized controlled trial. BMJ 2001;322:697–701.

63. Rizzo JA, Friedkin R, Williams CS, et al. Health care utilization and costs in a Medi-

care population by fall status. Med Care 1998;36(8):1174–88.

64. Shaw FE, Bond J, Richardson DA, et al. Multifactorial intervention after a fall in

older people with cognitive impairment and dementia presenting to the accident

and emergency department: randomised controlled trial. BMJ 2003;326:73.65. Jensen J, Lundin-Olsson L, Nyberg L, et al. Falls and injury prevention residential

care-effects in residents with higher and lower levels of cognition. Ann Intern Med

2002;136(10):733–41.

66. Jensen J, Nyberg L, Gustafson Y, et al. Falls and injury prevention residential

care—effects in residents with higher and lower levels of cognition. J Am Geriatr

Soc 2003;51(5):627–35.

67. van Dijk PT, Meulenberg OG, Van De Sande HJ, et al. Falls in dementia patients.

Gerontologist 1993;33:200–4.

68. Marcus BH, Williams DM, Dubbert PM, et al. Physical activity intervention studies:

what we know and what we need to know: a scientific statement from the Amer-ican Heart Association Council on Nutrition, Physical Activity, and Metabolism

(subcommittee on physical activity); council on cardiovascular disease in the

young; and the interdisciplinary working group on quality of care and outcomes

research. Circulation 2006;114:2739–52.

69. van der Bij AK, Laurant MG, Wensing M. Effectiveness of physical activity inter-

ventions for older adults. Am J Prev Med 2002;22:120–33.

70. Yardley L, Donovan-Hall M, Francis K, et al. Older people’s views about falls

prevention: a qualitative study. Health Educ Res 2006;21:508–17.

71. Yardley L, Donovan-Hall M, Francis K, et al. Attitudes and beliefs that predict

older people’s intention to undertake strength and balance training. J GerontolA Biol Sci Med Sci 2007;62:P119–25.

72. Yardley L, Todd C. Promoting good balance: encouraging older adults to under-

take activities that improve balance. J Active Aging 2007;46–52.

73. Becker C, Kron M, Lindemann U, et al. Effectiveness of a multifaceted interven-

tion on falls in nursing home residents. J Am Geriatr Soc 2003;51:306–13.

Rose & Hernandez630

http://http//www.profane.eu.org/news.phphttp://http//www.profane.eu.org/news.php


25/25

74. Dyer CA, Taylor GJ, Reed M, et al. Falls prevention in residential care homes:

a randomised controlled trial. Age Ageing 2004;33:596–602.

75. Sakamoto K, Nakamura T, Hagino H, et al. Effects of unipedal standing balance

exercise on the prevention of falls and hip fracture among clinically defined high-

risk elderly individuals: a randomized controlled trial. J Orthoped Sci 2006;11:

467–72.

76. Schoenfelder DP. A fall prevention program for elderly individuals. Exercise in

long-term care settings. J Gerontol Nurs 2000;26(3):43–51.


the role of exercise in fall prevention for older adults

Documents