Physical Activity, Older People and Falls: Research Update The effects of ageing on performance Exercise to prevent falls Holistic benefits of exercise Specific strength training benefits Inactivity in the UK Exercise as part of a multifactorial intervention

AGEING AFFECTS ALL OF US 1-2% in functional ability p.a. Strength Power Bone density Flexibility Endurance Balance and co-ordination Mobility and transfer skills Show of hands: Who in this room is over 30 years of age? Well all of you who raised your hand are ageing! Every year you have a 1-2% reduction in function – based on what you had the year before/ Sedentary behaviour accelerates the loss of performance...

Thresholds for quality of life Move through this slide briefly The solid line represents an average gain in strength which plateaus around 20-25 years, then declines The bottom dotted line shows someone who has young onset of disease, or sedentary behaviour – there is a lower peak performance. The top line represents an athlete. Ageing will affect them in a similar way, but they will cross the threshold value at a later age Sit to stand no arms, then low chair arms folded, then on one leg. By the age of 80, half on muscle strength will be lost, and this is what it may feel like to get up from a chair when you are old. This is why most older people will need to use their arms to rise from a chair

Strength to be confident of rising from low chair without using arms QUADRICEPS STRENGTH 12 Men Women 10 8 Knee extension strength (N/kg) 6 4 2 This slide uses information from the ADNFS – 4000 people measured who didn’t have any illness. The bars=range, and square or circle=average Men are stronger than women Women are markedly less able to stand from a chair at a younger age The dotted line is the threshold for starting to need the arms to assist sit to stand. The average 50 year old woman is equivalent to a 65-69 year old man. Strength to be confident of rising from low chair without using arms Age (years) 50-54 60-64 70-74 50-54 55-59 60-64 65-69 55-59 65-69 70-74

FUNCTION FOR LIFE Wash hair comfortably? 20% women & 14% of men > 50 do not have sufficient shoulder flexibility Confident of getting out of a chair without using arms ? 25% women & 7% men aged 70 – 74 do not have sufficient leg strength Ease of stair use? 47% women aged 70 – 74 do not have sufficient leg power Walk comfortably at a 20 minute a mile pace? Nearly 10% men & over 35% women aged 50 – 74 do not have sufficient aerobic capacity 35% men and 80% women aged 70 – 74 The fitness survey also looked at shoulder flexibility and leg power. 1 in 5 women >50 do not have enough shoulder movement to style the back of their hair 80% women aged 70-74 become breathless walking at a 20min/mile pace IN THE ABSENCE OF DISEASE

NSF for OP: Exercise Evidence Standards 3 Intermediate Care 5 Stroke 6 Falls 7 Mental Health 8 Promotion of Health and active life in old age BRIEF! This man is 85 years old! There are 8 standards in the NSF OP, and in 5/8 exercise is mentioned as a treatment or prevention

Rubenstein & Josephson 2002 Causes and risks Fall causes Individual risk factors: Accident /Environment 31% Gait /Balance /Weakness 17% Dizziness vertigo 13% Drop attacks 9% Confusion 5% Postural hypotension 3% Visual disorder 2% Syncope 0.3% Other 15% Unknown 5% Weakness 11/11 Balance deficit 9/9 Mobility limitation 9/9 Gait deficit 8/9 Visual deficit 5/9 Cognitive impairment 4/8 Impaired ADL 5/9 Postural hypotension 2/7 A review of risk factors in 2002 showed that Gait problems, balance, weakness and mobility problems were not only cited as the one of the main cause in most falls but that that they were significant risk factors in nearly all the trials where they were measured in individuals. This study was a meta-analysis of 11 trials of risk factors and causes of falls. The individual risk factors are listed in order of importance, and all 11 trials found that weakness was the most the most important risk factor 31% of falls are accidental or due to the environment. Rubenstein & Josephson 2002

Sedentary vs active lifestyles >3 hrs per week targeted exercise myocardial infarct - 3 x less likely Osteoporosis - 2 x less likely Fall-related injuries - 2 x less likely Hip fracture - 2 x less likely WHO, 1996 “regular physical activity helps to “preserve independent living” and “postpone the age associated declines in balance and co-ordination that are major risk factors for falls” Walking as an exercise is not enough to reduce falls. A brisk walking trial carried out by Ebrahim (? Year - 1997) found an increased number of injuries and falls in the target group. You’re 3 x less likely to have a heart attack than a fall.

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 Reducing Fear Reducing Long Lies Reducing Institutionalisation Even if we don’t stop all falls we can increase quality of life, reduce fear, long lies and institutionalisation. Many will “fall better”, be able to get up again or not curtail their activity. Also, even if exercise is non-specific, falls risk factors can be reduced by improving strength. No trial has proved that we have reduced fractures by exercise, but there is evidence to suggest that the # site is changed (i.e. more wrist #, less hip #).

Fracture Prevention Triangle Exercise can increase BMD and alter bone properties FRAGILITY Exercise can increase muscle strength (padding) and improve reaction times Exercise can reduce falls FRACTURE Muscle is good padding! But it has been shown that you need to exercise for > 12 weeks at high intensity to increase bulk, this does not happen in many health services. FALLS FORCE National Institute for Health, USA 1999

Specificity of Exercise to Reduce Falls Province, 1995 Group and individual balance and strength training >65’s Wolf, 1996 Group Tai Chi >65’s (NOT >70’s at risk, Wolf 2003) Campbell, 1997 Home-based exercise >80’s Robertson, 2001 Home-based exercise >65’s and >80’s Day, 2002 Group exercise >70’s at risk Barnett, 2003 Group exercise >65’s at risk Lord, 2003 Group exercise >60’s retirement village Means, 2003 Group exercise >65’s, psychosocial effects Liu-Ambrose, 2004 Group exercise for >75s with low bone mass Skelton, 2005 Group exercise >65’s frequent fallers Her are a selection of studies – as you can see there is a range of older adults covered, in a range of settings

Not “ALL” Exercise works to Prevent Falls Effective Ineffective to prevent falls but effective on falls risk factors………… Barnett 2003 Lord 2003 Morgan 2004 Skelton 2005 Buchner 1997 Campbell 1997 Campbell 1999 Cornillon 2002 Day 2002 Robertson 2001 Wolf 1996 Bunout 2005 Campbell 1999, 2005 Carter 2002 Ebrahim 1997 Latham 2003 Lord 1995 McMurdo 1997 Mulrow 1994 Pereria 1998 Reinsch1992 Schnelle 2003 Steinberg 2000 Wolf 2003 In pairs: Close your books. What do you think would make an exercise intervention ineffective? Duration Type Non-progressive Frequency e.g. x1/week But you might think that any exercise will do, unfortunately it won’t, these are some examples...

? Insufficient tailoring or specificity Ebrahim trial – mentioned earliwe. In the Pereira trial, people were healthier but fell just as much These trials were of good duration but not specific.

Effective Duration of Exercise Provision / Benefit Strength, Power, Static balance, Gait 8-12 wks Dynamic balance, Endurance 12-24 wks Bone strength (hip, spine and wrist) 36+ wks Dizziness and Postural Hypotension 24+ wks Transfer skills 24+ wks Mood, Depression, anxiety, self-esteem 12+ wks Falls 15-52 wks Physiological studies: Exercise shown to increase muscle strength and improve balance thus provide rational for using it to attempt tp reduce falls. Frailer people and those with falls history require longer exercise interventions to reduce falls. Those studies that were effective over 15 weeks were those with mild deficits and no falls history. Effective trials ranged from 15-52 weeks. The trial by Wolf, and the one by Day showed a significant diference in older adults, but not frail adults. In practice, Falls Services tend to see those at greatest risk, and last for far less than 52 weeks! So we need to refer patients on for ongoing progression.

Is Tai Chi the answer? Tai Chi Evidence is Limited (Verhagen 2004 Review) Reduces trips and falls: In older adults with mild deficits of strength and balance (Wolf 1996) In older adults who are inactive (Li 2005) Reduces fear: In frail fallers (Sattin 2005) Helps gait: In patients with vestibular disorders (McGibbon 2005) Helps stability and balance: In patients with vestibular disorders (McGibbon 2004) In older people aged 80+ (Wolfson 1996) Tai Chi practitioners have similar balance under challenging somatosensory conditions as younger adults (Wong 2001; Tsang 2004) BUT does NOT reduce risk of falls in frail older adults (Wolf 2003) Tai Chi: (Atlanta FICSIT): 48% reduction (adjusted for fall risk factors) cf computerised balance training programme (interestingly only control gp improved balanced showing importance of fall as primary measure (Mcmurdo) . Delete 2nd bullet point under reduces trips and falls Tai Chi has been shown to reduce fear – the mental health benefits of Tai Chi should not be forgotten. Wolf, 2003 – Tai Chi does not reduce falls risk in frailer adults…if balance is too poor, then you cannot bring in the true 3D element until much later.

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%

FaME – Group & Home-based Randomised controlled trial – Exercise Only Women aged 65+, > 3 falls last year Exercise-only intervention – 9 months Falls decreased by 60% Injurious falls decreased by 75% Skelton et al. Age Ageing 2005 The FaME trial was carried out with frequent fallers (>3 falls in the previous year), average age 82 years. Unlike OTAGO which was 1 year, this was a 9 month programme, carried out twice a week, backed up by a home exercise programme. To date this is the most effective exercise programme for falls. Not all falls were prevented, but the number of injurious falls was reduced Co-workers: O.Rutherford and S.Dinan

STRENGTH / POWER / ASYMMETRY Significant isometric and isokinetic improvements in the exercise group: Ankle Plantarflexion 60% Ankle Dorsiflexion 40% Ankle Inversion 25% Ankle Eversion 30% Hip Flexion 20% Lower Limb Power 25% Asymmetry reduced 15% Within 6 weeks of # NOF the lady on the right was back in class This was research rather than practice. There was decrease in asymmetry.

BALANCE & MOBILITY Significant improvements were seen in balance, FR, TUAG and floor rise

BONE Text underneath graph to be removed Below 0 is worse, above is improved These are all just different ways of measuring BMD. The exercise group maintained or improved BMD, the control group lost BMD. Only 1% improvement in the spine, with all that work – bone does not respond as quickly as muscle to training. Significant difference with time and group for L2-L4 spine and Wards Triangle (F=3.46, p<0.05). Exercisers n=32, Controls n=14. Time between visit 1 and visit 2 = mean 10.9 (sd 2.7) months

FALLS DURING INTERVENTION Exercisers slightly increased risk of falls compared to controls (RR 1.19) less likely to have injurious fall (RR 0.51) DURING FOLLOW UP Exercisers had half the risk of falls compared to controls (RR 0.53) ++ less likely to have injurious falls (RR 0.39) THREE YEARS FROM BASELINE 10% of exercisers had died, were in Hospital /in a nursing home vs 33% of controls The exercise group may have increased their falls risk on commencing exercise due to increased confidence, but they fell better due to increased flexibility.

QUALITY OF LIFE Improvements in ALL domains of SF36 Self-reported improvements in Caring skills Playing with grandchildren Bathing instead of showering Using public transport again Reduced anxiety and fear Confidence Fallen Angels Club Meet every two months in Starbucks, Oxford Street, London, UK! This is what the participants thought of the programme – never mind what we found! By the end of the trial all were using public transport again. And they all still meet up regularly.

MORBIDITY AND MORTALITY 80% of over 80’s would rather be dead than suffer the loss of independence that moving to a nursing home would bring (Salkeld, 2000). It’s NEVER TOO LATE (Fiatarone, 1990) It’s never too late, even if someone is in a nursing home. This study carried out hourly exercise sessions 3x/week for 12 weeks with chair bound residents. There was a 200% improvement in 1 rep max which is equivalent to a 30-35% increase in strength. This was the same result of training as with a 30 year old – and all the participants were over 90. In the oldest old, the aim is maintenance of independence regardless of disease, rather than disease prevention

Can exercise prevent fractures? Lifetime risk of hip fracture Men 3 in 100 Women 15 in 100 Fractures more common in sedentary people No current studies show exercise can reduce fractures It is possible to increase BMD in older people (Welsh 1996; Kohrt 1995; Verschueren 2004) It is possible to increase BMD in fallers (Skelton 2005; Liu Ambrose 2004) Trials needed to reduce fractures with exercise would require a very large number of participants Slide to be removed

Conclusions of Systematic Review of Exercise and Falls 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

WHAT’S THE DIFFERENCE? Gardening Physical Activity DIY Housework any bodily movement produced by skeletal muscles that results in energy expenditure. Exercise planned, structured and repetitive bodily movement undertaken to improve or maintain one or more components of physical fitness. Bouchard 1990 Gardening DIY Housework Bowling Walking Cycling Exercise class Sports We exercise in order to improve physical activity Physical activity – anything that makes you warmer Exercise – what we’re providing, components to improve a specific problem.

THE BENEFITS OF EXERCISE Prevention of : disease Coronary Heart Disease, Osteoporosis, Obesity, Stroke, Depression, Type 2 Diabetes, Hypertension, Some Cancers disability Arthritis, Intermittent claudication, Angina, Sleep, Low back pain complications of Constipation, Deep vein thrombosis, immobility Oedema, Pressure sores isolation Socialisation, Self-efficacy, Confidence dependence Functional ability, Falls, Autonomy, Dignity, Caring skills In Manchester, a long-stay ward carried out passive cycling movements on residents’ legs. The result was they no longer needed to use laxatives on the ward Exercise can help all these conditions. 41 cancers are associated with lack of physical activity.

BENEFITS OF REGULAR PHYSICAL ACTIVITY IMPROVES OR MAINTAINS Good posture & body image Intake of nutrients and immunity to infection Cerebral function, mood, memory Sleep pattern and duration Social contacts INDEPENDENCE AND QUALITY OF LIFE REDUCES OR PREVENTS Falls risk and fear of falling Breathlessness, fatigue Incontinence, urinary urgency Anxiety, Depression, Stress Sleep, social, fatigue, incontinence, anxiety/depression are all risk factors for falls What is the recommended activity level to maintain good health? DEPENDENCE AND ISOLATION

No standing activity leads to active loss of bone and muscle HOW MUCH IS ENOUGH? Adult population - physical activity of a moderate intensity for half an hour, on at least five days of the week. (Department of Health 1999) Maintenance of Independence - once/twice a week minimum – specific, progressive exercise (Consensus) No standing activity leads to active loss of bone and muscle For maintenance purposes exercise does not need to be as regular, but it does need to be specific and progressive.

A VISCIOUS CYCLE OF INACTIVITY Physical deterioration - Heart disease - High blood pressure - Aches and pains - Osteoporosis Increasing age Further decrease in physical activity Less exercise Social / psychological ageing - Feeling ‘old’ - ‘Acting’ one’s age - Increased stress - Anxiety, depression - Low self-esteem Decreased physical abilities - Increased body fat - Sagging muscles - Decreased energy Older people worry that exercise may exacerbate their conditions.

UK’S SEDENTARY WAYS 40% of people aged 50 or over in the UK are sedentary 60-85% are sedentary in ethnic minority groups Half of the sedentary over 50’s and 2/3 of over 70’s believe they take part in enough physical activity to keep fit. We don’t have very good role models on TV. Sedentary means less than ½ hour of any moderate activity in 1 week. Moderate activity = makes you warm and breathless. A gentle stroll to the shops is not enough! Ethnic minority groups are more active in their own countries than here – why? Access, more care available here?

Inactivity related disease? Disuse rather than disease? 1 wk bed rest  strength by ~ 20% 1 wk bed rest  spine BMD by ~1% Nursing home residents spend 80-90% of their time seated or lying down - leading to ‘Inactivity related disability’ Often what people consider as disease is actually disuse. In a study, medical students were paid to stay in bed for a week, catheterised etc, strength was reduced by 20%. In an older person, this could tip you over the # threshold. 20% reduction in strength takes 3 months to regain, and to regain 1% BMD you would need to exercise for 9 months, 3x/week at high intensity. And if you think about the NH residents they have decreased BMD and strength on top of frailty.

Walk from Home - Keighley Walk with me ! Walk from Home - Keighley Mary Moffat - 93 Referred by physio after a fall Loss of confidence and fear of falling Isolated and lonely and dependent upon others to get out In this project, a PT Assistant visited 4-5 times a week to increase confidence and outdoor mobility.

BUT not all physical activity is safe for fallers! RCT Increasing physical activity in people with previous upper arm fracture (Ebrahim 1997) Intervention: Brisk walking Control: exercise of upper arm Falls risk ↑ (Brisk walking > control) Fracture risk ↑ (Brisk walking > control) Beware unsafe pavements! PA / Exercise has a complicated relationship with falls – more activity increases exposure to risk…. NICE 2004 do not recommend brisk walking! We talked about this a little bit earlier This and other trials are the reason why NICE don’t recognise brisk walking. Not only are the least active at risk the most active are too as they start to do more.

Physical Activity vs Falls Brisk walking correlates with better postural stability in postmenopausal women (Brooke-Wavell 1998). Yet a brisk walking intervention in fallers caused an increased incidence of falls and fractures (Ebrahim 1997) Most falls occur at periods of maximal activity (Luukinen 1994) Yet, Hip fractures are less common in active people (Gregg 1998) U-shaped relationship in amount of physical activity and number of falls (Gregg 1998) Community dwelling frequent fallers are less habitually active than non-fallers (Skelton 2002) Slide to be removed One study showed that in postmenopausal women, regular brisk walking correlated with better postural stability (Brooke-Wavell 1998). Yet, an early intervention (RCT) to reduce falls, recommended brisk walking to women who had attended a fracture clinic for an upper arm fracture. The women in the study group had significantly more falls and fractures than those not recommended to increase their outdoor walking (Ebrahim 1997). The majority of falls in community dwelling older people take place during periods of maximal activity (Luukinen 1994). In contrast, the risk of hip fractures is up to 40% lower in the most active compared with the least active people (Gregg 1998). There may be a U-shaped relationship between the amount of physical activity and the number of falls, with a higher incidence of falls in the least active and the most active (Gregg 1998) (PS. Those most active will be exposing themselves to more risk (going out more often) and more risky activities (rambling etc.). Those least active will have poor strength, balance and power) Skelton’s trial of community dwelling frequent fallers (>3 falls previous year) showed that, compared to non-fallers, they were less habitually active (using the self-completed Habitual Activity Profile Questionnaire.

Unsupported forward flexion may be risky for those with previous spinal fractures……. Type of Exercise Reoccurrence of Fracture Back extension 16% Flexion (abd. curls) 89% Combined 53% No exercise 67% To further complicate the relationship of exercise with fractures – this trial shows that unsupported forward flexion (ab curls) increases the chance of having a further spinal fracture a year after the first spinal fracture diagnosed!! Compared to doing NO EXERCISE AT ALL!! However, back extns preserved spinal integrity by reducing the rate of refracture to only 16%. In this study there were 4 groups Those that did nothing – re# rate was approx 70% Back ext only – good for the spine, re# rate 16% Abdo curls only – significant increase in re# - almost 90% Combined back ext and abdo curls – 53% Sinaki & Mickelson 1982

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

Population Approaches including increasing physical activity Do they work? Significant decreases or downward trends in fall-related injuries reported in five large studies Relative reduction in fall-related injuries 6 to 33% All Interventions included Education, advice, medication use, footwear, home hazard reduction, promotion of physical activity Some included public lighting, public roadways, housing planning Finally, what about a population approach to falls prevention? McClure has just completed a systematic review for the Cochrane Library. Although there were no randomised controlled trials (almost impossible when it is a whole town or city being studied against another!) five trials met scientific scrutiny and all showed decreases in fall-related injuries (people attending hospital or GPs). All the trials included information leaflets, radio talks, etc on what increased risk, what reduced risk, footwear and the need to be fit and active and concentrate on balance skills. Some included making the environment safer for the older person as well. The trials were all in Europe and Australia, as yet there have been no trials in the UK. All trials showed a good reduction in falls and injury, suggesting that getting info out to a wide group does appear to work. There have been 5 large trials comparing one community to another, they used leaflets, pharmacy / med reviews, home hazards with literature, media – and on a population basis it seems to work. McClure et al. 2005 Systematic Review

Comparison to NICE guidance 81% run strength and balance training classes BUT Average duration 8 weeks and frequency once per week! This slide is to be moved. So have Falls services in the UK taken up the challenge of providing exercise opportunities for fallers? Well, yes, almost! 80% run strength and balance classes in their services – great – BUT, average duration is 8 weeks, once a week and this is not following the evidence base! So your challenge, should you chose to accept!! Is to influence practice when you leave here today! Ensure effective referral from the rehab setting onto the community setting!! Lamb et al, SDO report, 2007

“Man does not cease to play because he grows old “Man does not cease to play because he grows old. Man grows old because he ceases to play” George Bernard Shaw If I’d known I was going to live this long, I’d have taken better care of myself Dubey Blake