Exercise for preventing falls in older people living in the community

Background

At least one-third of community-dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have previously been found to prevent falls in these people.

Review aim

To assess the effects (benefits and harms) of exercise interventions for preventing falls in older people living in the community.

Search date

We searched the healthcare literature for reports of randomised controlled trials relevant to this review up to 2 May 2018. In such studies, people are allocated at random to receive one of two or more interventions being compared in the study. Leaving group allocation to chance helps ensure the participant populations are similar in the intervention groups.

Study characteristics

This review includes 108 randomised controlled trials with 23,407 participants. These were carried out in 25 countries. On average, participants were 76 years old and 77% were women.

Certainty of the evidence

The majority of trials had unclear or high risk of bias, mainly reflecting lack of blinding of trial participants and personnel to the interventions. This could have influenced how the trial was conducted and outcome assessment. The certainty of the evidence for the overall effect of exercise on falls was high. Risk of fracture, hospitalisation, medical attention and adverse events were not well reported and, where reported, the evidence was low- to very low-certainty. This leads to uncertainty regarding drawing conclusions from the evidence for these outcomes.

Key results

Eighty-one trials compared exercise (all types) versus a control intervention that is not thought to reduce falls in people living in the community (who also had not recently been discharged from hospital). Exercise reduces the number of falls over time by around one-quarter (23% reduction). By way of an example, these data indicate that if there were 850 falls in 1000 people followed over one year, exercise would result in 195 fewer falls. Exercise also reduces the number of people experiencing one or more falls (number of fallers) by around one-sixth (15%) compared with control. For example, if there were 480 fallers who fell in 1000 people followed over one year, exercise would result in 72 fewer fallers. The effects on falls were similar whether the trials selected people who were at an increased risk of falling or not.

We found exercise that mainly involved balance and functional training reduced falls compared with an inactive control group. Programmes involving multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduced falls, and Tai Chi may also reduce falls. We did not find enough evidence to determine the effects of exercise programmes classified as being mainly resistance exercises, dance, or walking programmes. We found no evidence to determine the effects of programmes that were mainly flexibility or endurance exercise.

There was considerably less evidence for non-fall outcomes. Exercise may reduce the number of people experiencing fractures by over one-quarter (27%) compared with control. However, more studies are needed to confirm this. Exercise may also reduce the risk of a fall requiring medical attention. We did not find enough evidence to determine the effects of exercise on the risk of a fall requiring hospital admission. Exercise may make very little difference to health-related quality of life. The evidence for adverse events related to exercise was also limited. Where reported, adverse events were usually non-serious events of a musculoskeletal nature; exceptionally one trial reported a pelvic stress fracture and a hernia.

Authors' conclusions: 

Exercise programmes reduce the rate of falls and the number of people experiencing falls in older people living in the community (high-certainty evidence). The effects of such exercise programmes are uncertain for other non-falls outcomes. Where reported, adverse events were predominantly non-serious.

Exercise programmes that reduce falls primarily involve balance and functional exercises, while programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises plus resistance exercises). Tai Chi may also prevent falls but we are uncertain of the effect of resistance exercise (without balance and functional exercises), dance, or walking on the rate of falls.

Read the full abstract...
Background: 

At least one-third of community-dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have been found to prevent falls in these people. An up-to-date synthesis of the evidence is important given the major long-term consequences associated with falls and fall-related injuries

Objectives: 

To assess the effects (benefits and harms) of exercise interventions for preventing falls in older people living in the community.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers up to 2 May 2018, together with reference checking and contact with study authors to identify additional studies.

Selection criteria: 

We included randomised controlled trials (RCTs) evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We excluded trials focused on particular conditions, such as stroke.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.

Main results: 

We included 108 RCTs with 23,407 participants living in the community in 25 countries. There were nine cluster-RCTs. On average, participants were 76 years old and 77% were women. Most trials had unclear or high risk of bias for one or more items. Results from four trials focusing on people who had been recently discharged from hospital and from comparisons of different exercises are not described here.

Exercise (all types) versus control

Eighty-one trials (19,684 participants) compared exercise (all types) with control intervention (one not thought to reduce falls). Exercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.71 to 0.83; 12,981 participants, 59 studies; high-certainty evidence). Based on an illustrative risk of 850 falls in 1000 people followed over one year (data based on control group risk data from the 59 studies), this equates to 195 (95% CI 144 to 246) fewer falls in the exercise group. Exercise also reduces the number of people experiencing one or more falls by 15% (risk ratio (RR) 0.85, 95% CI 0.81 to 0.89; 13,518 participants, 63 studies; high-certainty evidence). Based on an illustrative risk of 480 fallers in 1000 people followed over one year (data based on control group risk data from the 63 studies), this equates to 72 (95% CI 52 to 91) fewer fallers in the exercise group. Subgroup analyses showed no evidence of a difference in effect on both falls outcomes according to whether trials selected participants at increased risk of falling or not.

The findings for other outcomes are less certain, reflecting in part the relatively low number of studies and participants. Exercise may reduce the number of people experiencing one or more fall-related fractures (RR 0.73, 95% CI 0.56 to 0.95; 4047 participants, 10 studies; low-certainty evidence) and the number of people experiencing one or more falls requiring medical attention (RR 0.61, 95% CI 0.47 to 0.79; 1019 participants, 5 studies; low-certainty evidence). The effect of exercise on the number of people who experience one or more falls requiring hospital admission is unclear (RR 0.78, 95% CI 0.51 to 1.18; 1705 participants, 2 studies, very low-certainty evidence). Exercise may make little important difference to health-related quality of life: conversion of the pooled result (standardised mean difference (SMD) -0.03, 95% CI -0.10 to 0.04; 3172 participants, 15 studies; low-certainty evidence) to the EQ-5D and SF-36 scores showed the respective 95% CIs were much smaller than minimally important differences for both scales.

Adverse events were reported to some degree in 27 trials (6019 participants) but were monitored closely in both exercise and control groups in only one trial. Fourteen trials reported no adverse events. Aside from two serious adverse events (one pelvic stress fracture and one inguinal hernia surgery) reported in one trial, the remainder were non-serious adverse events, primarily of a musculoskeletal nature. There was a median of three events (range 1 to 26) in the exercise groups.

Different exercise types versus control

Different forms of exercise had different impacts on falls (test for subgroup differences, rate of falls: P = 0.004, I² = 71%). Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies; high-certainty evidence) and the number of people experiencing one or more falls by 13% (RR 0.87, 95% CI 0.82 to 0.91; 8288 participants, 37 studies; high-certainty evidence). Multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88; 1374 participants, 11 studies; moderate-certainty evidence) and the number of people experiencing one or more falls by 22% (RR 0.78, 95% CI 0.64 to 0.96; 1623 participants, 17 studies; moderate-certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99; 2655 participants, 7 studies; low-certainty evidence) as well as reducing the number of people who experience falls by 20% (RR 0.80, 95% CI 0.70 to 0.91; 2677 participants, 8 studies; high-certainty evidence). We are uncertain of the effects of programmes that are primarily resistance training, or dance or walking programmes on the rate of falls and the number of people who experience falls. No trials compared flexibility or endurance exercise versus control.

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