Therapeutic Exercises in Fall Prevention among Older Adults

Abstract

Falls constitute a leading cause of injury-related mortality and morbidity, threatening the independence of older adults. Physical activity levels tend to decrease as the quality of life among older adults with an increasing fear of falls. Exercises of varying types are beneficial in preventing falls among older adults. Despite the assertion that therapeutic exercises are crucial in preventing falls among older adults and promoting their overall health, there is no evidence to favor any exercise type. However, exercise regimens address deficits and needs, plus recommendations exist for regular physical activity. This chapter focuses on falls among older adults. The authors discussed epidemiology, risks, and prevention of falls. Research evidence supports exercises in managing falls with increasing physical activities, quality of life, and reduced fall-related injuries and risks. The chapter highlights the benefits of multifaceted, single-intervention exercises and the Otago Exercise Programme.

1. Introduction

Falls remain the third leading cause of chronic disability among older adults over 65 [1]. Falls are common in older adults and portend serious problems including physical, injury-related, and psychological health challenges for older adults [2], leading to injury-related morbidity, mortality, and nursing home placement among this population [3]. Aging is associated with increased morbidity, increased fear of falling, and reduced activity, consequently impairing the quality of life of older people. Falls are prevalent among the elderly population. One in three community-dwelling people aged over 65 years falls each year [4, 5]. Burns, Stevens, and Lee [6] reported that one in four people would decrease yearly. Akosile et al. [7] similarly reported a prevalence rate of 27.8% among a sample of older adults in a Nigerian community.

Falls constitute a significant cause of fatal and nonfatal injuries among adults aged ≥65 years [8]. Several factors increase the risks of falls among older adults. Risk factors are intrinsic: related to an individual, and irrelevant: related to the environment. According to Bagiartana and Huriah [9], balance disorders in adults are the primary cause of falls, a significant health concern for older adults. Older people in nursing homes and hospitals also experience falls, which have multifactorial etiology. Tinetti et al. [10] followed up with a large cohort of older adults. They identified increasing age, female gender, certain medications, history of falls, impaired balance, and lower extremity weakness as significant predictors of falls. In a prospective study of fall risk factors among community-dwelling older adults, muscle weakness, balance impairments, visual impairments, chronic diseases, and cognitive impairment had a significant association with increased risk of falls [11]. Falling is not always reported at hospitals, even though more than one out of four older people falls yearly. Burns, Steven, and Lee [6] said less than half of fall incidents get reported to doctors, and falling once makes you a perpetual faller [12].

In a systematic review, Park [13] reported that falls significantly cause injuries and death in people over 65 [14]. Their systematic review and meta-analysis of observational studies said that risk factors such as previous falls, impaired balance, gait disorders, lower extremity weakness, visual impairments, and polypharmacy were strongly associated with increased fall risk. Rubenstein [15] highlighted factors such as muscle weakness, gait and balance impairments, medications, visual impairment, environmental hazards, chronic conditions, and cognitive decline as significant contributors to fall risk. Falls can result from a combination of risk factors rather than a single cause. Identifying and addressing these risk factors through appropriate interventions, such as exercise programmes, home modifications, medication adjustments, and regular health assessments, can significantly reduce the risk of falls among older adults.

In a study among a community-dwelling sample of older adults, fear of falls was present in nearly one of every four older adults. Distribution is like that among individuals with actual falls [16]. Falls lead to injury and even death in older adults. Fear of falls increases among older adults, and their physical activity levels tend to decrease as age increases, leading to reduced quality of life [2]. According to King and King [2], midlife and older adults represent the most inactive portion of the studied population, and there exists a significant relationship between physical activity, fear of falls, and the quality of life of older adults [17].

Falls among older adults are very costly. Park [13] reported that falls are a significant cause of injury and death in people over 65. In the USA, about $50 billion annually goes to medical costs related to nonfatal fall injuries, and $754 million is spent on fatal fall injuries [18]; this cost will increase as people live longer [19]. Martin et al. [20], in their systematic review of the modified Otago Exercise Programme (OEP), reported that using OEP-modified formats improved balance and functional ability. Kyrdalen et al. [21] asserted that the OEP, with its emphasis on strength and balance exercises, proved to be effective for fall prevention and reducing fall risks. The authors concluded that exercise interventions could reduce fall risks in older adults. Still, the value of different types of exercise activities differs for older adults, as evidence in the literature does not seem to favor any exercise [22].

Therapeutic exercise programmes, specifically for fall prevention, focus on improving strength, balance, flexibility, and coordination. Long-term exercise promotion is recommended for fall prevention. In addition to these physical benefits, therapeutic exercise programmes for fall prevention can positively affect older adults’ confidence, self-efficacy, and overall quality of life. Regular participation in these programmes can significantly reduce the risk of falls and their associated consequences. This chapter focuses on falls among older adults, their impacts on aging and vice versa, and the evidence that exercises have been effective in falls, increasing physical activity, and quality of life in this population.

2. Epidemiology of falls

Aging is a critical stage in human life characterized by a series of changes that occur in internal and external organs. These changes help humans adjust to their immediate surroundings. Improving health care and general life services through science and technology has increased the number of older persons. As people age, they experience significant public health concern that results, in most occurrences, in morbidity, cost of health care services, and mortality [23].

Fall is a significant public health concern among older adults, and a faller is someone who has a fall in a stipulated period of 6 months or 1 year [24]. According to Nabavi et al. [25], fall is one of the most common and severe problems among older adults. The World Health Organization sees a fall as an unexpected event where an individual falls to the ground from the same or higher level. It is an event that results in a person coming to rest accidentally on the ground, floor, or other lower level [26]. Older adults are often at risk of falls resulting in severe injuries or even death. Injury from falls in the aging adult population has become widely accepted as a critical health problem [27].

Falls are one of the leading causes of disability and death among older adults or the geriatric population [23, 28]. In a meta-analysis, Salari et al. [29] reported the global percentage of falls among older people from Asia, Europe, Africa, America, and Oceania to be 25.6%. The report showed that the highest prevalence rate of falls in older adults was 34.4% among Oceanians and 27.9% among Americans. Europe’s record fall among older adults was 23.4% and the lowest, followed by 25.4 and 25.8% prevalence rates among Africans and Asians, respectively.

Globally, the prevalence of falls in the older adult population in 2022 was 26.5%. In 2012, Japan had a 20.9% prevalence rate of falls, against 15.9% in 2011 [30] and a 28% prevalence rate for Japan in 2018 [31]. Brazil report showed that falls are prevalent, with one in every three older adults experiencing more than one fall in 12 months [32]. In America, falls among adults 65 and older recorded 3 million emergency department visits, causing over 36,000 deaths in 2020 [33]. From Japan’s experience, there has been an increase in the number of fallers, which consequently places a more significant burden on care delivery, because of the attendant injuries and morbidity.

Africa also has an aging population, although slower than other world regions. By 2050, the proportion of people aged 60 and older adults in Africa will increase from 5 to 10 percent. The increase in the number of older adults may be dramatic, from 47.4 million in 2005 to two billion by 2050 [34]. In Nigeria, a fall prevalence rate of 23% was reported in 2010, with females experiencing a higher prevalence (24%) of falls compared to males (17.9%) [35, 36]. In 2014, a prevalence rate of 27.8% was reported among older adults (65 years and above) in Nigeria [37]. Older adults in urban areas experience more falls than their counterparts in rural communities. Twenty-five percent (25.3%) of older adults in rural areas reported experiencing a fall within 6 weeks, while a higher percentage of participants (41.3%) in urban communities reported experiencing a fall [37]. In a hospital-based study in Ghana, the prevalence of falls was 40.2% [38]. A study in Malawi reported the prevalence of falls in older adults as 41% [39]. There are very few articles published on the prevalence of falls in Africa. Nevertheless, the increasing adult population is likely a public health concern and a significant reason for emergency department attendance.

Falls are preventable but continue to be a leading cause of mortality, morbidity, and decreased quality of life among older adults already burdened by many other conditions. Globally, the prevalence rate of falls in the aging adult population is at a rate of 1 in 4 or 25.6% prevalence. Oceania has the highest prevalence record of 34.4%, the lowest prevalence rate for Europe at 23.4%, and fall prevalence in Africa is not different from that reported globally.

3. Risk factors for falls

Falls are one of the major causes of injuries, morbidity, and mortality among older adults, impacting older people’s quality of life [13] and resulting in social isolation [40]. Identifying the risk factors associated with falls is critical for preventing falls and their consequences [15, 41]. The risk of falls increases with age [42] and the number of risk factors in each person [43]. There are several risk factors for falls in older adults [44]. Risk factors for falls among older adults are multifactorial [26, 44]; and can be classified as extrinsic or intrinsic factors [45, 46] or modifiable and non-modifiable risk factors.

Intrinsic (within-subject) risk factors are those factors related to the individual’s specific risk, such as demographic and biological factors, while extrinsic risk factors comprise environmental and behavioral factors [45]. Intrinsic risk factors include previous history of falls, age, gender, living alone, ethnicity, medical conditions and chronic illnesses, impaired mobility and gait, loss of foot sensation, sedentary lifestyle, psychological status, fear of falling, nutritional deficiencies, visual and cognitive impairments. In contrast, extrinsic risk factors include environmental factors (poor lighting, slick floors, slippery bathrooms, rough surfaces), footwear and clothing, and unsuitable walking aids [47, 48].

Modifiable risk factors refer to those risk factors that can be improved or alleviated with an intervention. In contrast, non-modifiable risk factors are those factors that cannot improve with intervention or any treatment [14, 43, 49]. However, most of the associated risk factors for falls and recurrent falls can be modified [42]. According to the American Geriatric Society/British Geriatric Society, modifiable fall risk factors include muscle weakness, imbalance, gait problems, polypharmacy, incontinence, mobility deficits, orthostatic hypotension, and syncope. In contrast, non-modifiable fall risk factors include age, female gender, history of prior falls, and certain chronic health conditions such as dementia, Parkinson’s disease, and stroke.

The World Health Organization (WHO) classified risk factors for falls into four categories: biological, behavioral, environmental, and socioeconomic factors [26]. In their systematic review and meta-analysis, Li et al. [50] found depression, history of falls, visual impairment, age, balance disorders, female gender, fear of falling, and dementia as risk factors for falls. Other authors have reported risk factors for falls as a history of previous falls, gait alterations, osteoporosis, loss of functional capacity, fear of future falls, cardiovascular problems, fatigue, and the environment [51, 52]; depression [53, 54]; cognitive impairment [55]; urinary incontinence [54]; polypharmacy (use of ≥ four drugs) [46, 53, 56, 57, 58]; visual impairments [54]; use of ambulatory devices [53]; comorbidities [54, 56, 57, 58] female gender [42, 54, 59]; diabetes mellitus [42, 59, 60], presence of balance or gait problems or foot abnormalities, and use of antihypertensive [42].

There is an association between diminished balance and reduced physical functioning, plus an increased risk of falling among individuals over 65. Some environmental factors, for example, poor lighting, clutter in and around the house, and improper footwear, are also risks for falls among older persons [43]. Falls often result from a mixture of risk factors rather than a single cause. Identifying and addressing these risk factors through appropriate interventions that include exercise programmes can significantly reduce the risk of falls among older adults. The knowledge, understanding, and exploration of these risk factors would identify areas for improvement and inform targeted interventions that enhance fall prevention which is paramount to improving patient outcomes and reducing the burden of falls.

4. Therapeutic exercises in fall management

Therapeutic exercise is crucial in preventing falls among older adults and promoting their overall health and well-being. Exercise interventions incorporating balance and strength are often components of fall prevention strategies. The effort is usually toward alleviating the numerous debilitating consequences using interventional strategies to prevent falls [61] and improving the overall well-being of older adults. According to [62], prevention of falls can decrease morbidity and mortality among older adults. Sherington et al. [63] reported that interventions that pose an increasing challenge to balance at a higher dose have better fall prevention effects.

Therapeutic exercise programmes for fall prevention focus on improving strength, balance, flexibility, and coordination. Howe et al. [64], in their update of a Cochrane review, concluded that weak evidence supports gait, balance, coordination, and functional tasks, strengthening exercises in managing older adults for balance in 2007. Reduced balance is associated with reduced physical functioning and an increased risk of falling. 3D and multiple exercises were moderately practical immediately post-intervention for balance outcomes in older people [64]. Furthermore, there was insufficient evidence on general physical activity like walking and exercise involving computerized balance programmes or vibration plates [64].

Effective fall prevention strategies are multifactorial interventions targeting specific risk factors and exercises for muscle strengthening with balance training. Weidermann et al. [65], in their meta-analysis on exercise-based reduction of falls, concluded that physical activity and balance exercise are the most effective and rated isolated postural control above multifactorial approaches among community-dwelling older adults.

Research interest in fall prevention intervention began in the 1970s in developed countries. The Center for Disease Control and Prevention (CDC) included information on effective fall prevention interventions in the third edition of the Compendium [66]. Evidence shows that suitably and adequately recommended interventions can prevent falls [1]. Exercise is an evident preference as a fall prevention intervention because defective muscle strength and poor postural control increase fall risks but improve with exercise [64, 67]. Research shows that numerous studies have evaluated different exercise programmes to prevent falls. Exercise is a cost-effective fall prevention strategy [68] and is effective when delivered in a group or individualized setting [69].

The 4th edition of the Centers for Disease Control and Prevention (CDC) Compendium classifies single and multifaceted interventions [70]. Cuevas-Trisan [62] reported the effectiveness of multidimensional intervention strategies for falls. Multifaceted interventions that incorporate exercise have been proven effective in fall prevention. Multifaceted interventions include therapeutic exercise programmes for fall prevention, containing a combination of different forms of exercise to address multiple risk factors simultaneously. These programmes may include education on fall prevention strategies, such as home safety modifications and proper footwear. In their systematic review with meta-analysis, Hopewell et al. [71] reported that exercise is the most common component, including multifaceted interventions for preventing falls in older adults. Individually tailored fall prevention exercise programmes are more common than general programmes.

Multifaceted or multi-component interventions are designed to address multiple fall risk factors by providing participants with two or more individually tailored intervention plans following a pre-executed personalized fall risk assessment. These interventions may include components such as assistive technology, environmental assessment with modifications, quality improvement strategies, and basic fall risk assessments [70, 72]. These strategies had varied combinations of the following interventions: exercise, home/environmental assessment and modification, education, psychological interventions, medication modification/management, vision management, urinary incontinence management, fluid or nutrition therapy including calcium and vitamin D supplementation, sunlight exposure, surgery, referral to appropriate specialists, hip protection. Exercise management of falls is a common denominator often complemented by other interventions to create a comprehensive approach that addresses the broader factors contributing to falls.

A good number of studies with multifaceted intervention strategies have reported significant positive effects on falls [73, 74, 75]. Some other studies reported no significant impact of multifaceted interventions on falls [76, 77], while another study found no apparent overall effects of these interventions on falls [78]. A standard, consistent component of multiple interventions significantly associated with reducing the number of fallers and falls rate were exercise, assistive technology, environmental assessment with modifications, quality of life improvement strategies, and basic fall risk assessment. Multifaceted interventions were associated with a reduction in fall rate [RR 0.87; 95% CI 0.80–0.95] but not with a decrease in the number of fallers [RR 0.95; 95% CI 0.89–1.01] [79].

Exercise management of falls is a common denominator often complemented by other interventions to create a comprehensive approach that addresses the broader factors contributing to falls. Single intervention strategies for falls include exercises; cognitive behavioral therapies, environmental or home modification, cognitive-motor interference; manual therapy; virtual reality games; interactive-motor interventions, mind-body interventions involving meditative movements, podiatry, vision intervention, and fall hazard identifications [80, 81, 82, 83, 84]. Dautzenberg et al. [79], in a recent meta-analysis with 192 studies, said that single intervention exercises were significantly associated with a reduction in falls rate (RR 0.79; 95% CI 0.73–0.86).

According to the CDC compendium, some single intervention exercises for falls were reported: Simplified Tai Chi, Wolf, et al. [85]; Tai Chi: Moving for Better Balance, Li et al. [86]; The Otago Exercise Programme, Campbell et al. and Robertson et al. [87, 88, 89]; Adapted Physical Activity Programme, Kovacs et al. [90]; Freiberger et al. [91]; Falls Management Exercise [FAME] Intervention, Skelton et al. [92]; LiFE (Lifestyle Approach to Reducing Falls Through Exercise), Clemson et al. [93]; Multi-target Stepping Programme, Yamada, et al. [94]; Senior Fitness and Prevention [SEFIP], Kemmler et al. [95]; Stay Safe, Stay Active, Barnett et al. [96]; Strength and Exercise Programme, Kim et al. [97]; PreFalls (Prevent Falls) Programme, Siegrest et al. [98].

The Otago Exercise Programme [OEP] is widespread. It is one of the most tested fall prevention programs by the Centers for Disease Control and Prevention [20, 99]. OEP increases balance and strength, and decreases fall rates, with several other health benefits for older people [100], with a 35% reduction in falls proven [100]. In its original form, the exercise programme comprises individually tailored strength, balance, and endurance exercises plus home-based support, and additional follow-up by telephone over a total exercise period of 1 year. Exercises are performed three times per week, with extra walks twice weekly.

The OEP also positively affected health outcomes when performed two times per week [101]. Dadgari et al. [102] reported that in the experimental group, the mean fall incidence declined from 1.58 to 1.26 from pre- to post-intervention assessment, showing that the Otago exercise programme significantly reduced the incidence of falls. Findings from Kiik et al. [103] showed that the Otago training significantly reduced the risk of falling among the studied older adults (p = 0.041). The risk of falls in the intervention group decreased from 14.26 to 12.05 s and increased from 12.94 to 13.26 s in the control group. In their scoping review, Mgbeojedo et al. [104] reported that when the OEP was administered in either group setting or on an individualized basis, it effectively reduced falls. Additionally, balance, strength, mobility, and health-related quality of life within the community and institutionalized older adults were improved.

Regular walking has been suggested as a complement to increase physical activity levels [105]. However, for active and healthy older people with a low fall risk, the OEP’s goal to reduce falls may not be sufficiently challenging [106]. This phenomenon highlights the importance of identifying older people who will benefit from fall prevention exercise programmes such as the OEP. The OEP is empirically supported single intervention for fall prevention: a stand-alone programme comprising four home visits over 8 weeks, according to the following schedule: weeks 1, 2, 4, and 8 [107]. It consists of leg muscle strengthening, balance retraining exercises progressing in difficulty, and a walking plan. Each person receives a booklet with instructions for each exercise prescribed and ankle cuff weights (starting at 1 kg) to provide resistance for the strengthening exercises. The OEP programme takes about 30 minutes to complete. To help them adhere to the programme, participants record the days they end it, and the instructor telephones them each month between home visits. Follow-up home visits are conducted every 6 months.

The key components of therapeutic exercise are balance and stability exercises which aim to improve balance and stability by targeting the core muscles, and the lower body. Strengthening exercises for muscle strength are essential for maintaining balance and stability. Stretching exercises help improve and maintain flexibility and range of motion in joints, which enhance mobility, and reduce the risk of falls, progressive challenges, and task-specific training. Task-specific training involves practicing daily activities that older adults commonly encounter, such as stepping over obstacles, reaching for objects, or navigating stairs. These exercises reduce the risk of falls among older adults and have been effective in multifaceted and single programmes with an individual approach.

5. Conclusion

Falls are a significant public health concern. Individualized and multifaceted exercise programmes are essential fall prevention strategies, reducing fall risk and improving the overall well-being of older adults. The current trend in exercise management of falls among older adults focuses on evidence-based and multifaceted approaches that integrate various components to address multiple risk factors tailored to individual needs. Despite the efforts in place, fall prevalence continues to increase globally. One in three older adults falls once a year, one in four are recurrent fallers, and older adults experience fear of falling with or without a history of falling. This trend warrants public health attention globally. Assessing the risks of falls as part of routine health care for older adults is necessary.