Exercise to reduce falls risk: the research and application

1. Exercise to reduce falls risk: the research and application Professor Keith Hill, School of Physiotherapy Keith.Hill@Curtin.edu.au Gippsland Workshop: September 2014

2. Overview • How effective is exercise in reducing falls in older people (focus on people without dementia) • Different options for exercise to reduce falls in older people • Factors to consider in exercise prescription • Addressing barriers to exercise participation

3. various forms of exercise balance strength cardiovascular fitness flexibility specificity of training other health benefits of exercise programs Exercise strong evidence of effectiveness of training in older people to improve specific risk factor

4. What works in falls prevention for older people in the community setting • There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries: • exercise (home exercise; tai chi, group exercise) • cataract extraction / change multifocal glasses to 2 sets of glasses • psychotropic medication withdrawal / medication review • home visits by Occupational Therapists • improved post hospital discharge follow-up • approaches to support client uptake in recommended interventions • vitamin D and calcium supplementation (in low vit D cases) • cardiac pacemaker for carotid sinus hypersensitivity • foot exercise, footwear and orthoses • multiple interventions based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED) COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)

5. Participation in falls prevention exercise by older Australians • Randomly selected sample (>5,000 participants, 61% response rate) Merom et al, Prev Med, 2012; 55:613-7

6. Evidence of what works in exercise in falls prevention • Group exercise programs • Home exercise programs (often prescribed by a physiotherapist • Tai Chi- (note: different types of Tai Chi may have different effects) • Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011) Cochrane review: Gillespie et al 2012 (159 trials with 79,193 participants)

7. Exercise and falls prevention: what we know… 54 RCTs (all settings, though most in community) Sherrington et al 2011

8. Exercise interventions • Sample with disabling foot pain and increased falls risk • Intervention=foot & ankle exercise, footwear subsidy, and orthoses provision • Intervention group had 36% fewer falls, p<0.05 Spink M et al,, .BMJ. 2011 Jun 16;342:

9. Exercise interventions • At risk sample – falls or injurious fall in past 12/12 • Intervention=Lifestyle Integrated Functional Exercise • Compared LiFE program vs structured exercise program vs control • 31% reduction in falls (LiFEvs control, p<0.05) Clemson L,, et al .BMJ. 2012 Aug 7;345:e4547

10. Exercise parks for older people • Exercise parks for older people (Finland: Lappset) • recently commenced study at Victoria University http://www.lappset.com/global/en/ Pro_Play/The_Elderly_.iw3

11. Appropriate exercise prescription - Horses for courses 24 form Beijing style – Yang style Tai chi for arthritis – Sun style Very frail/ High falls risk Healthy older people CONTINUUM OF BALANCE IMPAIRMENT Otago Exercise Program “Otago Plus” – incl VHI kit

12. Supervised exercise or home exercise - issues to consider? • Safety concerns • Frail / high falls risk • Limited self - discipline • Impaired memory (potential role of carer)

13. Balance exercise cannot include hand support needs to target balance deficits safety (boxed in) functional vs non functional dynamic in preference to static for balance exercises to be effective, they need to challenge the balance system safely Classification from Merom et al, Prev Med, 2012

14. Framework for modulating task difficulty Bernhardt & Hill – 2005

15. Important components of exercise • goal oriented • safety • intermittent reappraisal of performance / feedback • regular practice / repetition • functional context • fun / enjoyable / social

16. Principles of exercise prescription for older people with increased falls risk • Based on • assessment findings (eg functional tests) • circumstances of falls • patient interests and activities • Observe performance of selected exercise for safety and accurate performance • Written instructions and contact number • Start off with low dosage and intensity relevant to assessment findings • Encourage fitting into daily routine • Intermittent review and modification as required

17. Evidence of detraining when an exercise program is stopped • 12 week weight bearing (home based) exercise program (3 times / week) vs seated resistance exercise vs social visit • Loss of up to 50% of balance gains in the subsequent 12 weeks after ceasing exercise Vogler et al, 2012, Arch Phys Med Rehabil; 93: 1685-91

18. Adherence in falls prevention interventions (Nyman and Victor, Age and Ageing, 2012) • Reviewed 99 randomised trial in 2009 Cochrane review (falls prevention in the community) • Adherence rates (n = 69) were: • ≥80% for vitamin D/calcium supplementation; • ≥70% for walking and class-based exercise; • 52% for individually targeted exercise; • approximately 60-70% for fluid/nutrition therapy and interventions to increase knowledge; • 58-59% for home modifications; • Adherence to multifactorial interventions was generally ≥75% but ranged 28-95% for individual components. Home-exercises on average 11 times per month CONCLUSIONS: Using median rates for recruitment (70%), attrition (10%) and adherence (80%), we estimate that, at 12 months, on average half of community-dwelling older people are likely to be adhering to falls prevention interventions in clinical trials.

19. Barriers to exercise for older people • chronic conditions (eg arthritis) • perception that exercise will aggravate pain • access (cost / transport) • no-one to exercise with • perception that exercise is not appropriate / beneficial for older people • lack of awareness of • benefits • available options (locally) Hill and Murray, 2004. Physical activity & falls prevention (chapter in book edited by Morris and Schoo)

20. Anne-Marie Hill et al, 2011, The Gerontologist

22. Summary • Generally low exercise participation levels in older people - need for approaches to improve participation • Exercise approaches can achieve positive fall related outcomes for older people, across the falls risk / frailty continuum • Strong research evidence that falls can be reduced through exercise interventions, especially • those with a balance component • those with >50 hours dosage • Most research has excluded people with dementia • Need to consider balance ability, safety and patient preference • Major issue of uptake and longer term adherence