This article presents a commentary on Sherrington et al's (2020) updated review on the association between physical activity and falls prevention in older adults. Falls are common in the older population (Al-Aama, 2011) and occur in 30% of all people over the age of 65 years every year (Lord et al, 2007). This amounts to 4290 falls per 100 000 people in the UK (James et al, 2020). Falls can affect all aspects of an individual's life, resulting in an increased chance of depression (Biderman et al, 2002), anxiety (Lavedán et al, 2018), reduced social participation (Pin and Spini, 2016) and increased morbidity and mortality (Berková and Berka, 2018). Falls can occur in the community due to multiple factors, such as a previous history of falls, gait problems, vertigo and medication (Deandrea et al, 2010). A recent Cochrane review has demonstrated that physical activity can help to reduce the number and rate of falls (Sherrington et al, 2019). This review has since been updated to reassess the effectiveness of physical activity on reducing fall rates in older people and to update World Health Organization (WHO) guidelines (Sherrington et al, 2020).
Methods
Sherrington et al's (2020) systematic review involved a vigorous search of nine databases from the date of inception to 7 November 2019. This included searches for ongoing and recently completed trials. Only randomised controlled trials (RCTs) that evaluated the effects of physical activity interventions on falls were included. Other inclusion criteria were: (1) population-that is, people aged 60 years and over and living in the community. Studies including younger patients were included if the mean age minus one standard deviation exceeded 60 years old; (2) intervention-any physical activity as a single intervention where the main aim was to investigate the role of exercise; (3) outcome-studies that reported the rate of falls per person-year. Studies with participants living in places that provide health-related care or those with health conditions that increase the risk of falls, such as stroke, were excluded.
The inclusion of trials was assessed independently by two reviewers, and disagreement was resolved by a third party. Risk of bias was assessed using the Cochrane risk of bias tool. The Grading of Recommendation Assessment, Development and Evaluation (GRADE) framework was used to evaluate the certainty of the evidence using the categories of high, moderate, low and very low confidence. The effectiveness of interventions for reducing the rate of falls was reported using rate ratios (RaRs) with 95% confidence intervals. Heterogeneity was assessed using forest plots and the chi-squared test. Subgroup analyses, sensitivity analysis and meta-regressions were undertaken (Sherrington et al, 2020).
Results
The database and registry search identified 2396 studies. After screening, nine studies were eligible for inclusion and added to the original list of 108 studies from the 2019 Cochrane review (Sherrington et al, 2019). After removal of one feasibility study, which was replaced with the recently published full trial, 116 RCTs were included, of which 10 were cluster randomised. A total of 25 160 participants were included from 29 countries, of which 74% were women. A high risk of bias in the included studies was identified most frequently for selective reporting of outcomes (45% of studies), incomplete outcome data (28%) and sampling bias (26%). Significant heterogeneity of included studies ranged from minimal to substantial, likely to represent differences between study populations and exercise programmes, such as dose or intensity.
Sixty-four of the included trials reported the rate of falls and were included in the meta-analysis. The duration of exercise programmes included in the analysis was between 5 weeks and 2.5 years, and total hours of exercise ranged from 6 to 312 hours. There was statistically significant evidence that all types of exercise reduced the rate of falls by 23% compared with the control (RaR, 0.77; 95% CI, 0.71–0.83) based on high-certainty evidence.
Further sub-group analysis was performed and showed no difference in the rate of falls for participants who were 75 years or older compared with those aged 60–74 years. Similarly, there were no differences between those participants at an increased risk of falling as an inclusion criterion and those recruited generally, between group and individual exercise or between intervention delivered by a health professional and that delivered by a trained exercise leader.
A sub-group analysis was undertaken on the different types of exercise. Balance and functional exercise reduced the rate of falls by 24% compared with the control groups (RaR, 0.76; 95% CI, 0.70–0.82), based on 39 studies of high-certainty evidence. Multiple-type exercises (commonly, balance and function plus resistance exercises) showed a 28% reduction (RaR, 0.72; 95% CI, 0.56–0.93), based on 15 studies with moderate-certainty evidence. Tai Chi exercise showed a 23% reduction (RaR, 0.77; 95% CI, 0.61–0.97), based on 9 studies of moderate-certainty evidence. The effectiveness of dancing and walking programmes was uncertain based on a few studies with very low-certainty evidence.
Meta-regression identified a dose-response relationship between the duration of exercise and the reduction in the rate of falls, although this was not statistically significant. Balance and functional exercise programmes with a dose of 3 hours plus per week were particularly notable in reducing the risk of falls by 42% (incidence RaR, 0.58; 95% CI, 0.45–0.76).
Commentary
The process of the systematic review was evaluated using the Amstar2 critical appraisal tool and scored 12/16. The unfulfilled criteria referred to elements of the included studies that were not clearly reported in the review, such as the types of control group, sources of funding and the impact of reported bias. However, these elements were reported in the 2019 Cochrane review (Sherrington et al, 2019), prior to the update provided from the nine new studies. Further limitations acknowledged by the review authors include potential omission of non-English studies and issues of reviewer subjectivity in the classification of exercise. Overall, the review was deemed of high quality, providing an accurate and comprehensive summary of the results of the available studies that address the question of interest.
All forms of exercise programmes identified in the review reduced the rate of falls by nearly a quarter in adults over 60 years. Based on the findings, effective exercise programmes for fall prevention should aim to include balance and functional resistance exercises. These factors could also be combined to take the form of a Tai Chi class. Additionally, exercise programmes should aim to be carried out at moderate or greater intensity at least three or more days a week, according to the updated WHO guidelines (Bull et al, 2020). When encouraging patient participation, it is also recommended that health professionals promote activity change where possible and address potential barriers, such as low self-belief and fear of falling (National Institute for Health and Care Excellence (NICE), 2021). It is unclear which age group and level of risk of falling would benefit the most from an exercise programme. Therefore, no triage recommendations based on these two criteria can be made at the moment.
The delivery of exercise programmes for falls prevention can be flexible in terms of who delivers them and whether they are completed on an individual or group basis. However, it is not clear which settings would be the most beneficial given that exercises can be completed at home, with the additional option of technology-based interventions. Evidence has indicated that a home-based exercise programme to prevent falls in older adults (using an exercise manual and supervision) showed a significant reduction in the rate of falls compared with usual care (Liu-Ambrose et al, 2019). An economic evaluation has also recommended that home-based exercise programmes targeting effective falls strategies in high-risk groups are value for money and make an economically valid choice (Davis et al, 2010). Technology-based interventions such as gaming exercise have also been shown to improve physical or cognitive functions in older adults, such as balance, mobility, self-confidence and reaction time, compared with usual or no care (Choi et al, 2017). Further reviews of the evidence in different types of environments are needed in order to establish which are the most effective.
Patient factors for participation should also be considered if falls prevention programmes are to be successfully implemented. Reported barriers for undertaking physical activity in older people include environmental context and resources (affordability of programmes, safety, accessibility and time), beliefs about capabilities and social influences, including cultural barriers and the influence of family and friends (Spiteri et al, 2019). To overcome such barriers and support patient participation, NICE (2021) recommended a flexible approach to accommodate different needs and preferences, provision of relevant information and discussions with patients to consider the changes a person is willing to make.
KEY POINTS
- Falls are common in older adults (those aged 65 years and over), and they can have serious repercussions, including depression, reduced social participation and increased morbidity and mortality
- Falls can occur in the community due to multiple factors, such as a previous history of falls, gait problems, vertigo and medication
- Several studies from across the world have shown that regular exercise can prevent falls among older adults
- This is particularly the case with exercise programmes that include balance and functional exercises
- Patient participation should be taken into consideration when planning falls-prevention exercise programmes for older adults
CPD REFLECTIVE QUESTIONS
- What factors are important when establishing a falls prevention class?
- What are the main limitations of the systematic review?
- If applicable, what other factors would you need to take consideration within your own practice to adopt these strategies?