Fall prevention with exercise in older adults
Table of contents
A 79-year-old man comes to the visit to renew prescriptions. Only at the end, almost in passing, his wife mentions that he fell twice in the last year, one of them in the bathroom, and that the second time he stayed on the floor until she came home from the street. He downplays it: he slipped, nothing broke. Since then he walks less and avoids going out alone.
The scene is common. Falls happen each year in about 30 of every 100 people over 65, and the proportion rises with age (Montero-Odasso, 2022). Many never reach the medical record, because older adults think falling is part of aging or fear losing autonomy if they tell (Montero-Odasso, 2022).
This text shows how the 2022 world guideline organizes screening and risk stratification, what the Cochrane reviews say about exercise and falls, which types of training work and in whom the evidence is strongest.
Key points
- The world guideline recommends asking about falls opportunistically and stratifying risk into low, intermediate and high (Montero-Odasso, 2022).
- In the 2019 Cochrane review, exercise reduced the rate of falls in older adults living in the community, with a rate ratio of 0.77 (Sherrington, 2019).
- Balance and functional exercises have the strongest evidence, of high certainty, with a rate ratio of 0.76 (Sherrington, 2019).
- Programs with more than 3 hours per week that include balance were particularly effective, with an estimated rate ratio of 0.58 (Sherrington, 2020).
- Exercise also reduced injurious falls, with a rate ratio of 0.63 for all injurious falls (El-Khoury, 2013).
- In long-term care facilities and hospitals, the effect of exercise on the rate of falls is still uncertain (Cameron, 2018).
Summary
- Why falls matter
- Who is at risk: screening and stratification
- What the evidence shows about exercise
- What type of exercise works
- Who benefits
- How to prescribe in practice
- Beyond exercise: the multifactorial approach
- How NEXO helps train this reasoning
- Frequently asked questions
- Take-home messages
Why falls matter
A fall seems like a trivial event, but it often marks a turning point in an older adult's life. It brings injuries, loss of confidence, less activity and, often, the start of a spiral of dependence.
The size of the problem
The world guideline notes that about 30 of every 100 people over 65 fall each year (Montero-Odasso, 2022). The authors expect the number of falls and injuries to rise, because there are more older adults and because multimorbidity, polypharmacy and frailty are more frequent (Montero-Odasso, 2022).
For the clinician, this means that falls are a routine problem. In primary care, they appear mixed with other complaints and must be actively sought.
Serious falls and time on the floor
Some falls weigh more. The guideline defines a serious fall as one with an injury that requires a medical visit, that leaves the person on the floor unable to get up for at least one hour, that leads to a visit to the emergency department or that comes with loss of consciousness (Montero-Odasso, 2022).
Time on the floor matters in itself. Among older adults who fall, about 1 in 8 stays on the floor for more than one hour (Montero-Odasso, 2022). This prolonged stay is associated with dehydration, pneumonia and other complications (Montero-Odasso, 2022). When the fall reaches the emergency department, the pitfalls are different, such as the fall from standing height with head trauma.
The fear of falling
After a fall, many older adults start avoiding activities. The fear of falling is common and is associated with serious physical and psychosocial consequences (Kendrick, 2014). With less movement, strength and balance worsen, and the risk of another fall rises.
This cycle explains why exercise is a central part of prevention. It acts on strength, gait and balance and, in part, on confidence (Kendrick, 2014).
Who is at risk: screening and stratification
The 2022 world guideline proposes a simple path. Every older adult receives guidance on fall prevention and physical activity, and those at higher risk receive more intensive assessment and intervention (Montero-Odasso, 2022).
Opportunistic screening
The starting point is a question: "Have you fallen in the last 12 months?" (Montero-Odasso, 2022). It is very specific for predicting new falls, but it has low sensitivity and lets many cases pass (Montero-Odasso, 2022).
To improve sensitivity, the guideline cites the three key questions: whether the person fell in the last year, whether they feel unsteady when standing or walking, and whether they are afraid of falling (Montero-Odasso, 2022). A positive answer leads to objective assessment of gait and balance (Montero-Odasso, 2022).
The way of asking makes a difference. Many older adults only mention the fall when they feel there is room in the consultation, which reinforces the value of making room for the patient's ideas, concerns and expectations.
Measuring gait
The guideline recommends gait speed as the main test, with a cutoff below 0.8 m/s, in a strong recommendation (Montero-Odasso, 2022). The Timed Up and Go (TUG) appears as an alternative, with a cutoff above 15 seconds, but with less consistent evidence for stratifying risk (Montero-Odasso, 2022).
This caution with the TUG comes from data. In a meta-analysis of community-dwelling older adults, the TUG with a cutoff of 13.5 seconds had a pooled specificity of 0.74 and sensitivity of only 0.31 (Barry, 2014). The authors concluded that the test is more useful for confirming risk than for ruling it out (Barry, 2014).
Low, intermediate and high risk
With the history and gait assessment, the older adult falls into one of three categories (Montero-Odasso, 2022):
| Category | Who is included | What to offer |
|---|---|---|
| Low risk | No falls, or one mild fall without change in gait or balance (Montero-Odasso, 2022) | Education about falls and exercise for general health, with annual reassessment (Montero-Odasso, 2022) |
| Intermediate risk | One mild fall with change in gait or balance (Montero-Odasso, 2022) | Targeted strength and balance exercise, or referral to a physiotherapist (Montero-Odasso, 2022) |
| High risk | Fall with injury, two or more falls in 12 months, frailty, one hour or more on the floor, or suspected transient loss of consciousness (Montero-Odasso, 2022) | Multifactorial assessment with individualized interventions (Montero-Odasso, 2022) |
The man in the case has two falls in the year and a long stay on the floor. According to the guideline, he is in the high-risk group (Montero-Odasso, 2022).
When the fall may be syncope
Suspicion of a fall due to syncope changes the direction of the investigation. The guideline calls for specific assessment and management of syncope in this scenario (Montero-Odasso, 2022). The reasoning starts by confirming syncope and looking for the cause, before attributing everything to balance.
Institutions and hospitals
In nursing homes and hospitals, the guideline considers all older adults to be at high risk (Montero-Odasso, 2022). In these settings, it recommends a broad standardized assessment followed by interventions in several domains (Montero-Odasso, 2022).
What the evidence shows about exercise
The most solid base comes from the 2019 Cochrane review on exercise in community-dwelling older adults. It included 108 randomized trials, with 23,407 participants from 25 countries (Sherrington, 2019).
Fewer falls and fewer people falling
Compared with control, exercise reduced the rate of falls, with a rate ratio of 0.77 (Sherrington, 2019). It also reduced the number of people who fall one or more times, with a relative risk of 0.85 (Sherrington, 2019).
The review commissioned for the World Health Organization physical activity guidelines updated this analysis. With 116 studies and 25,160 participants, the effect on the rate of falls remained, with a rate ratio of 0.77 and high-certainty evidence (Sherrington, 2020).
Falls with injury and fractures
Reducing falls is good, but what matters most is reducing the falls that cause harm. The meta-analysis by El-Khoury gathered trials with data on injurious falls in community-dwelling older adults (El-Khoury, 2013).
Exercise reduced every category assessed. The rate ratio was 0.63 for all injurious falls, 0.70 for falls that required medical attention, 0.57 for falls with serious injury and 0.39 for falls with fracture (El-Khoury, 2013).
In the Cochrane review, exercise may reduce fractures related to falls, with a relative risk of 0.73, but the certainty was low (Sherrington, 2019). Falls requiring medical attention also dropped, with a relative risk of 0.61 (Sherrington, 2019).
Fear of falling
The Cochrane review on fear of falling included 30 studies and 2,878 participants (Kendrick, 2014). Shortly after the intervention, exercise brought a small to moderate reduction in fear, with a standardized mean difference of 0.37 (Kendrick, 2014).
The certainty was low, and the effect at longer follow-ups remained uncertain, with very low quality evidence (Kendrick, 2014). Even so, the finding helps in the conversation with the patient who stopped leaving home.
Safety
Exercise to prevent falls is safe for most older adults. In the Cochrane review, 27 trials reported adverse events, and only 2 were serious: a pelvic stress fracture and a hernia surgery (Sherrington, 2019). The others were, in general, mild musculoskeletal complaints (Sherrington, 2019).
What type of exercise works
Exercise is a broad word. The reviews show that the type of training changes the result considerably.
Balance and functional exercise
Balance and functional exercises form the group with the firmest evidence. They reduced the rate of falls with a rate ratio of 0.76 and the number of people who fall with a relative risk of 0.87, both with high certainty (Sherrington, 2019).
In practice, these are activities that challenge the body's control while standing: shifting weight, narrowing the base of support, stepping in various directions, standing up and sitting down (Montero-Odasso, 2022). The goal is to train exactly the situations in which falls happen.
Multicomponent programs
Programs that combine types of exercise, usually balance and functional with resistance, also reduced falls (Sherrington, 2019). In the Cochrane review, the rate ratio was 0.66 (Sherrington, 2019). In the update for the World Health Organization, it was 0.72, with moderate certainty (Sherrington, 2020).
Tai chi
Tai chi reduced the rate of falls in the Cochrane review, with a rate ratio of 0.81 (Sherrington, 2019). In the update for the World Health Organization, the value was 0.77, with moderate certainty (Sherrington, 2020).
A randomized trial with 670 high-risk older adults tested a therapeutic version of tai ji quan, with two 60-minute classes per week for 24 weeks (Li, 2018). Compared with stretching, the incidence rate ratio of falls was 0.42 (Li, 2018). Compared with a conventional multimodal program, falls were lower in the tai ji quan group, with a ratio of 0.69 (Li, 2018). No serious adverse event was related to the intervention (Li, 2018).
Resistance training alone, walking and dance
For resistance training alone, dance and walking, the effect on falls remained uncertain in the Cochrane review (Sherrington, 2019). The international consensus on exercise in older adults adds that programs based only on walking are inferior to those that combine strength and balance (Izquierdo, 2021).
This has a direct implication. Recommending "walk more" to an older adult with impaired balance may be insufficient, and strength training alone, although useful for sarcopenia, needs to come together with a balance challenge when the target is falls (Izquierdo, 2021).
How much exercise
The amount seems to matter. Programs with more weekly hours had a greater reduction in falls, although the trend did not reach statistical significance (Sherrington, 2020). Programs with more than 3 hours per week that included balance and functional exercises were particularly effective, with an estimated rate ratio of 0.58 (Sherrington, 2020).
Who benefits
The practical question is whether every older adult should exercise to prevent falls or only those who have already fallen. The evidence gives different answers depending on where the person lives.
Older adults living at home
In the community, the benefit appeared both in those selected for increased risk and in those who were not (Sherrington, 2019). The subgroup analysis of the Cochrane review showed no difference in effect between the two groups (Sherrington, 2019).
For this reason, the world guideline recommends balance and functional exercise for all older adults in the community at risk, and physical activity guidance for all (Montero-Odasso, 2022). The low-risk older adult also benefits, because low risk is different from no risk (Montero-Odasso, 2022).
Long-term care institutions
In institutions, the picture changes. The Cochrane review on institutions and hospitals concluded that the effect of exercise on the rate of falls is uncertain and that it may make little or no difference to the risk of falling (Cameron, 2018).
The world guideline, even so, recommends supervised exercise in institutions, conditionally (Montero-Odasso, 2022). The high frailty and the cognitive conditions of this population help explain the weaker evidence.
Hospitals
In hospital, three trials tested additional physiotherapy in rehabilitation wards (Cameron, 2018). The evidence was of very low quality, and the effect on the rate of falls remained uncertain (Cameron, 2018).
During admission, other measures often weigh more, such as preventing and recognizing delirium. The text on what to do at the bedside in delirium details this care.
Frailty and high risk
The frail older adult or one with multiple falls needs more than an exercise prescription. The guideline calls for a multifactorial assessment for them (Montero-Odasso, 2022). Exercise is still present, but within a larger set of interventions (Montero-Odasso, 2022).
How to prescribe in practice
The world guideline translates the evidence into concrete recommendations for older adults in the community (Montero-Odasso, 2022).
Training content
The core is challenging and functional balance exercise, such as sit-to-stand and step training (Montero-Odasso, 2022). Whenever possible, tai chi or progressive resistance training is added (Montero-Odasso, 2022).
Frequency and duration
The recommendation is three or more sessions per week, individualized and progressive, for at least 12 weeks, and continued afterwards to maintain the benefit (Montero-Odasso, 2022). Strong recommendation, with high-quality evidence (Montero-Odasso, 2022).
The international consensus on exercise in older adults adds strength training at least 2 days per week in multicomponent programs (Izquierdo, 2021). It recalls that the combination of balance and strength is the most effective intervention to reduce falls (Izquierdo, 2021).
Progression and supervision
Balance only improves when it is challenged. This requires gradual progression, with increasingly difficult tasks, always safely. In those who have already fallen or have a very unstable gait, supervision by a physiotherapist at the start is prudent.
Adherence
The biggest obstacle is keeping up the exercise for months. The benefit depends on continuity, and for this reason the guideline recommends maintaining the program beyond the first 12 weeks (Montero-Odasso, 2022). Conversation techniques that explore the patient's own motivation have evidence of their own and can help.
Referring with clarity
When the case calls for physiotherapy, the referral letter should state the reason, the falls, the result of the gait tests and the goal of the training. There is a guide on what the letter to the specialist needs to say.
Beyond exercise: the multifactorial approach
For the high-risk older adult, exercise enters a larger set. The multifactorial assessment looks for the treatable causes of each person (Montero-Odasso, 2022).
What the reviews say
In the 2018 Cochrane review, multifactorial interventions may reduce the rate of falls, with a rate ratio of 0.77, but with low-quality evidence (Hopewell, 2018). For the risk of falling, there was little or no difference, with a relative risk of 0.96 (Hopewell, 2018).
The interventions most often applied after assessment were exercise, adaptation of the environment, medication review and psychological interventions (Hopewell, 2018).
The home environment
The 2012 Cochrane review on community-dwelling older adults showed that assessment and modification of home safety reduced the rate of falls, with a rate ratio of 0.81 (Gillespie, 2012). These interventions seemed more effective when carried out by an occupational therapist (Gillespie, 2012).
Medications
Polypharmacy is one of the drivers of the increase in falls pointed out by the guideline (Montero-Odasso, 2022). Medication review is among the interventions most often applied after multifactorial assessment (Hopewell, 2018). In people who use anticoagulants, a fall carries different weight, and the text on hidden bleeding in the anticoagulated older adult shows why.
Vitamin D
The world guideline recommends vitamin D supplementation only in those at risk of deficiency, and not as a general measure to prevent falls (Montero-Odasso, 2022).
Beware of excess
More tests and more interventions do not always bring more protection. The concept of cascades of care is a reminder that each step must have a clear reason.
Back to the case
The 79-year-old man has had two falls in the year and remained on the floor for a prolonged time, which places him in the high-risk group (Montero-Odasso, 2022). He needs a multifactorial assessment, with attention to the cause of the falls, to medications and to the home (Montero-Odasso, 2022). Balance and functional exercise, three or more times a week and progressive, is a central part of care (Montero-Odasso, 2022).
How NEXO helps train this reasoning
In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by searching for the ICD-10 code.
The limits of use of the game are described on the NEXO economy page. If you research the teaching of clinical reasoning, the page for researchers explains how to get in touch. Professionals who write or review cases find information under curation and under creators, and institutions can learn about the proposal on the partnerships page. For the most frequent reasons for consultation, see the most common codes in primary care.
Frequently asked questions
How many older adults fall each year?
About 30 out of every 100 people over 65 fall each year, and the proportion increases with age (Montero-Odasso, 2022).
What is the first question for screening for falls?
"Have you fallen in the last 12 months?" (Montero-Odasso, 2022). It is specific but not very sensitive, and can be complemented by questions about instability and fear of falling (Montero-Odasso, 2022).
Is the TUG enough to rule out fall risk?
It confirms risk better than it rules it out, with a pooled sensitivity of 0.31 in a meta-analysis (Barry, 2014). The guideline prefers gait speed (Montero-Odasso, 2022).
Who is considered high risk?
Anyone who has fallen and had an injury, has fallen two or more times in 12 months, is frail, has remained on the floor for an hour or more or has had suspected loss of consciousness (Montero-Odasso, 2022).
Which exercise prevents falls?
Balance and functional exercises, with high-certainty evidence (Sherrington, 2019). Tai chi and programs that combine strength and balance also work (Sherrington, 2019).
Does walking help prevent falls?
The effect of walking alone on falls is uncertain (Sherrington, 2019). Walking-only programs are inferior to those that combine strength and balance (Izquierdo, 2021).
How often should one train?
Three or more sessions a week, progressive, for at least 12 weeks and maintained afterwards (Montero-Odasso, 2022).
Does exercise reduce fractures?
It may reduce them, with a relative risk of 0.73 in the Cochrane review, but with low certainty (Sherrington, 2019). In a meta-analysis, falls with fracture had a rate ratio of 0.39 (El-Khoury, 2013).
Does exercise work in nursing homes?
The effect is uncertain in the reviews (Cameron, 2018). The guideline still recommends supervised exercise in these settings, conditionally (Montero-Odasso, 2022).
Take-home messages
- Falls affect about 30 out of every 100 older adults per year and must be actively sought.
- The world guideline stratifies risk into low, intermediate and high.
- A gait speed below 0.8 m/s is the preferred test (Montero-Odasso, 2022); the TUG confirms better than it rules out (Barry, 2014).
- Balance and functional exercise reduces falls with high-certainty evidence.
- Tai chi and programs that combine strength and balance also work.
- Walking or strength training alone have an uncertain effect on falls.
- Three or more sessions per week, for at least 12 weeks, and maintained.
- High risk calls for a multifactorial assessment, with exercise at the center.
Play the case of the day on NEXO.
References
- Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019. PMID 30703272. DOI 10.1002/14651858.CD012424.pub2.
- Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022. PMID 36178003. DOI 10.1093/ageing/afac205.
- Sherrington C, Fairhall N, Kwok W, et al. Evidence on physical activity and falls prevention for people aged 65+ years: systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act. 2020. PMID 33239019. DOI 10.1186/s12966-020-01041-3.
- El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ. 2013. PMID 24169944. DOI 10.1136/bmj.f6234.
- Kendrick D, Kumar A, Carpenter H, et al. Exercise for reducing fear of falling in older people living in the community. Cochrane Database Syst Rev. 2014. PMID 25432016. DOI 10.1002/14651858.CD009848.pub2.
- Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014. PMID 24484314. DOI 10.1186/1471-2318-14-14.
- Li F, Harmer P, Fitzgerald K, et al. Effectiveness of a Therapeutic Tai Ji Quan Intervention vs a Multimodal Exercise Intervention to Prevent Falls Among Older Adults at High Risk of Falling: A Randomized Clinical Trial. JAMA Intern Med. 2018. PMID 30208396. DOI 10.1001/jamainternmed.2018.3915.
- Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2018. PMID 30191554. DOI 10.1002/14651858.CD005465.pub4.
- Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2018. PMID 30035305. DOI 10.1002/14651858.CD012221.pub2.
- Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012. PMID 22972103. DOI 10.1002/14651858.CD007146.pub3.
- Izquierdo M, Merchant RA, Morley JE, et al. International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines. J Nutr Health Aging. 2021. PMID 34409961. DOI 10.1007/s12603-021-1665-8.