Exercise and Falls Prevention: In different settings Dr Dawn Skelton PhD Reader in Ageing and Health, HealthQWest, Glasgow Caledonian University Co-ordinator of Prevention of Falls Network Europe, University of Manchester

Exercise to Prevent Falls Exercise could help fallers in a number of ways: Reducing Falls (or injurious falls) Reducing known Risk Factors for Falls Reducing Fractures ? (or changing the site of fracture) Increasing Quality of Life & Social Activities Improving bone density Reducing Fear Reducing Institutionalisation Gardner 2000; Skelton & Dinan 1999; Skelton & Todd, 2005; NICE 2004

C Sherrington, JC Whitney, SR Lord, RD Herbert, RG Cumming, JCT Close Effective exercise for the prevention of falls – a systematic review and meta-analysis C Sherrington, JC Whitney, SR Lord, RD Herbert, RG Cumming, JCT Close 44 RCTs - 9603 participants JAGS, 2008

Results RR = 0.83 17% reduction in falls 95%CI 0.75-0.91 P<0.001 Moderate heterogenity I² = 62% moderate heterogeneity Sherrington et al., JAGS 2008

What makes the difference? Greatest effects of exercise on fall rates from interventions including: Highly challenging balance training High dose No walking program These 3 factors explained 68% of variance Sherrington et al., JAGS 2008 in press

Highly challenging Balance Training Exercise in standing involving: movement of the centre of mass narrowing of the base of support minimising upper limb support 24% Ratio of rate ratios RR 0.76 (95%CI =0.62 to 0.93) Sherrington et al., JAGS 2008 in press

High Dose 50+ hours At least 2 hours a week of exercise for at least 6 months Home or group-based or a combination of both 20% Ratio of rate ratios RR 0.80 (95%CI =0.65 to 0.99) Sherrington et al., JAGS 2008 in press

Adjusted effects of exercise on falls 42% Reduction: RR 0.58 (0.48 to 0.69) High balance High dose No Walking High balance Low dose No Walking 28% Reduction: RR 0.72 (0.60 to 0.87) Low balance High dose No walking 27% Reduction: RR 0.73 (0.60 to 0.88) High balance High dose Walking 24% Reduction: RR 0.76 (0.66 to 0.88)

Adjusted effects of exercise on falls No reduction: RR 0.95 (0.78 to 1.16) High balance Low dose Walking Low balance High dose Walking No reduction: RR 0.96 (0.80 to 1.16) Low balance Low dose No walking No reduction: RR 0.91 (0.79 to 1.05) Low balance Low dose Walking Increased risk: RR 1.20 (1.00 to 1.44)

Should we target high or low risk people? Trend towards better effect in low risk but no significant difference seen in high vs low risk groups High risk groups may be more cost effective to treat as more falls per person per year prevented Low risk groups could be targeted with a population based health promotion approach (greater reach) with the right messages (eg. Not just walking!) Sherrington et al., JAGS 2008 in press

Just balance ? Type Mix Balance and/or mobility (Essential) Resistance exercise (Very Important) Lower limb Most effective in weakest Aerobic / Endurance (Important) Flexibility (Important) Functional Task Training (Important) Mix Endurance or resistance training alone does not work Sherrington, 2008

Conclusions of Review Highly challenging balance training is an essential component of falls prevention exercise Exercise should take place at least twice a week for a minimum duration of 6 months Additional strength training for people with muscle weakness and / or aged over 80 Programmes should be progressed as a participant improves Walking should only be prescribed in addition to a high intensity / high dose programme Sherrington et al., JAGS 2008

New Zealand RCTs - OTAGO Individually tailored programme: Campbell, BMJ 1997 -80+ years, n=233, home-based, physiotherapist -1 year, falls  32%, injuries  39% Nurse delivered programme at home: Robertson, BMJ 2001 -75+ years, n= 240, home-based, district nurse -1 year, falls  46%,  serious injuries and hospital costs Nurse programme at GP centres: Robertson, BMJ 2001 -80+ years, n=450, home-based, general practice nurse -1 year, falls  30%, injuries  28% Physiological studies: Exercise shown to increase muscle strength and improve balance thus provide rational for using it to attempt tp reduce falls. FICSIT metan.(5comm, 2 Nh)-Province 1999,2-4 yrs, dif progs,subjects assigned to an x gp less likely to fall. No x component sig for injurious falls Cochrane review 1997- incons. Data. x alone did not protect against falls Tai Chi: (Atlanta FICSIT): 48% reduction (adjusted for fall risk factors) cf computerised balance training programme(interestingly only controlgp improved balanced showing importance of fall as primary measure (Mcmurdo) Campbell 1997: -cognitively intact, able to move around house - 4 1 hr visits over 2 months- individ 30 min progrm of strengthening exercises using ankle weights and balance training exercises included standing with one foot directlt in front of the other, walking tandem, heel walking, toe walking, knee squats. 3+ times a week and also walk outside home at least 3 times a week. -also relative hazard for injurious falls reduced and balance scores improved Campbell 1999 Age Ageing: rate of falls remained sig lower in the ex group than control gp at 2 years in those who continued the programme. Robertson; Nurse home: serious injuries and hosp admissions reduced. -cost /fall (1988 prices) Pv = NZ$1803 (£523) IRR = Inc rate ratio -cost / fall averted considering hospital costs NZ$155 (£45) Robertson: nurse. GP centres: no diff in serious injuries or hosp. Costs -cost/ fall averted : NZ$1519 (£441) Ebrahims 97, AgeAgeing brisk walking gp: falls up, therefore x is not x is not x. Qualified x practitioners-graded strengthening+ walking program Visually Impaired Older People: Campbell, BMJ 2005 -1 year, home-based. Only effective with full compliance, falls 28% 6 month programme: Liu-Ambrose, JAGS 2008 -70+ years, home-based, cognitive function improvements after 6 months and after 1 year falls 47%

What might work….but we don’t know? Just increasing habitual physical activity Different types of balance challenge in less frail older adults Bowls Line / Country / Scottish Dancing Working in an allotment Cycling Skiing ……etc

New technologies ? Wii-fit (Nintendo) ? Whole Body Vibration 6 mths, 3 x p/w post-menopausal women Strength 15%, Balance 20%, Hip BMD 1% Verschueren SM et al. 2004

Patients in Hospital Tai Chi + reaching + stepping + transferring chair to chair 1 physiotherapist to max 4 patients, 3 x p/w, 45 mins. 173 patients, 82 yrs, sub-acute ward Halved the number of falls (participant days in hospital) Haines et al. Clin Rehab 2007

Exercise alone? In high risk Not beneficial in care home residents RR 1.16 [0.81-1.65] Sherrington et al, 2008 ? Because the balance challenge is rarely great enough Needs strength and power focus too? Transfer training?

Part of a multi-factorial intervention…care homes Reduces falls - Becker et al. JAGS 2003 Improves mobility - Jensen et al. Aging Clin Exp Res 2004 Reduces falls risk factors - Dyer et al. Age Ageing 2004 Works better in those with cognitive impairment!!! – Rapp et al. 2008

Increasing engagement with exercise ? 60 people attending A & E as a result of a fall. When offered choice on an intervention to prevent a future fall 72% reluctant to take up exercise programme 28% reluctant to take osteoporosis medication But when asked if likely to take up an intervention to prevent a worsening health state 63% said they would take up exercise! 93% would take osteoporosis medication Whitehead 2006

Avoidance of activity? Falls prevention advice can induce anxiety and lead to activity restriction (AR) Exercise interventions perhaps should take account of: ‘Selectors’ See AR as a sensible approach to cope with their balance problems –poor adherence to exercise ‘Optimisers’ Better uptake and adherence to exercise as see increasing activity as a good approach to reducing falls ‘Compensators’ Tend to just adjust the activities they do rather than increase activities – more likely to accept home environmental advice and assistive walking aids Laybourne, Biggs, Martin, 2008

Changing Behaviour….. Adherence Most of those who take part in a 6 month programme continue to be afterwards….. Information and choice Assessments, goal setting Emphasize benefits to strength, balance and function rather than reducing falls What to expect from exercise Self efficacy Social support Ongoing supervision and support Yardley L, 2007 (ProFaNE) Sherrington, 2008

Final summary Exercise that challenges balance and improves gait / strength / power is best Exercise must be regular! Exercise has to be FOR LIFE – not 6-12 weeks! Exercise works even if people have many other medical risk factors Exercise may not stop a trip becoming a fall, but it will help reduce the “impact” of the fall and help people get back up again Exercise improves quality of life, social inclusion and helps autonomy and independence

8th World Congress on Aging and Physical Activity Aug 12-17 2012 Glasgow, UK “A celebration of diversity and inclusion in active ageing”