Effective Exercise for Fall Prevention—Research and Implementation

BC Injury Research & Prevention Unit Teleconference Series

September 17, 2009

Judy A. Stevens, Ph.D.

National Center for Injury Prevention & Control

Centers for Disease Control & Prevention

Outline

• Background on falls & fall risk factors

• What research tells us about exercise for fall prevention

• Identifying & implementing effective exercise programs

Introduction

• 30-35% of people 65+ fall each year1

• Those who fall are 2-3 times more likely to fall again2

• 10%-20% of falls cause serious injuries3

__________

1. Hornbrook, Gerontologist, 1994; Hausdorff, Arch Phys Med & Rehab, 2001 2. Tinetti, New Eng J Med, 1988; Teno, JAGS,19903. Sterling, J Trauma-Inj Infection & Critical Care, 2001

Leading Causes of Unintentional Injury Death Among People 65+, U.S., 2006

M.V.18%

Falls45%

Fire/Burn3%

Drowning1%

Other7%

Poisoning3%

Suffocation9%

Unspecified14%

__________

NCHS, Vital Records, 2006

Total = 36,700 deaths

Fall Death Rates by Sex & Age, U.S., 2006

020

406080

100

120140160

180200

65-69 70-74 75-79 80-84 85+

Age groups

Ra

te p

er

10

0,0

00

Men

Women

__________

NCHS, Vital Records, 2006

Trends in Age-Adjusted Fall Death Rates Men & Women 65+, U.S., 2000-2006

0

5

10

15

20

25

30

35

40

45

50

55

60

2000 2001 2002 2003 2004 2005 2006

Year

Ra

te p

er

10

0,0

00

Men

Women

___________

NCHS, Vital Records, 2006

35%

45%

Leading Causes of Nonfatal Injuries Among People 65+, U.S., 2007

Struck by/Against8%

MV Occupant5%

Overexertion6%

Cut/pierce4%

Other transport2%

Poisoning2%

All others7%

Bite/sting2%

Unknown2%

Falls62%

__________

NEISS-AIP, 2007

Total = 3.1 million injuries

N=1.9 million

Nonfatal Fall Injury Rates by Sex & Age, U.S., 2007

0

2000

4000

6000

8000

10000

12000

14000

65-69 70-74 75-79 80-84 85+

Age groups

Ra

te p

er

10

0,0

00

Men

Women

__________

NEISS-AIP, 2007

Trends in Age-Adjusted Nonfatal Fall Rates Men & Women 65+, 2001-2007

0

1000

2000

3000

4000

5000

6000

7000

8000

2001 2002 2003 2004 2005 2006 2007

Year

Pe

r 1

00

,00

0 P

op

ula

tio

n

Men

Women

_________

NEISS-AIP 2001-2007

8%

6%

Where Do Falls Happen?

• At home, outside…….......35%

• At home, inside…………..23%

• Away from home, in a

familiar place……………..23%

• Away from home, in an

unfamiliar place………….19%

______

Berg WP, Age & Ageing, 1997

When Do Falls Happen?

30%

52%

14%4%

______

Berg WP, Age & Ageing, 1997

0

25

50

75

100

Morning Afternoon Evening Night

Time of Day

Pe

rce

nt

of

Fa

lls

Why Do Falls Happen?

• Slipped or tripped…..… 59%

• Misplaced step……..…. 12%

• Loss of balance……….. 9%

• Legs give way ….……... 4%

• Other ……………………16%

______

Berg WP, Age & Ageing, 1997

Economic Impact

In 2000, cost of fall injuries among people 65+:

Total: ~ $19 billion

Fatal falls: $0.2 billion

Nonfatal injuries: $19 billion

___________Stevens, Injury Prev, 2006

Costs of Nonfatal Injuries

Sex• Men……......................... $ 5• Women…………………..$14

Types of injury• Fracture………………… $12• Superficial/contusion..... $

3• Other injuries…………... $

4

Quality of Life

20% - 36% fear falling1

20% die within a year after hip fracture2

25% in a nursing home one year later3

___________

1. Vellas, Age & Aging, 1997; Friedman SM, JAGS, 2002 2. Lu-Yao, AJPH, 19943. Magaziner, J Gerontology: Medical Sciences, 2000

Fall Risk Factors

• Biological

• Behavioral

• Environmental

__________

V. Scott, 2000

Leading Fall Risk Factors

__________

Rubenstein, Age & Aging, 2006

Risk Factor RRMuscle weakness 4.9

Balance problems 3.2

Gait problems 3.0

Poor vision 2.8

Limited mobility 2.5

Cognitive impairment 2.4

Functional limitations 2.0

Postural hypotension 1.9

Cochrane Review

ProFaNE exercise categories:

• Gait, balance or functional training

• Strength or resistance training

• Flexibility

• 3D (Tai Chi, dance, etc.)

• General physical activity

• Endurance

• Other_________

Gillespie, Cochrane Database of Systematic Reviews, 2009

Conclusions

“Multiple-component exercise interventions are effective in reducing the rate and risk of falling.”

“There is evidence for …3 different approaches…, multiple component group exercise, Tai Chi as a group exercise, & individually prescribed multiple component exercise carried out at home.”

What Kind of Exercise Works Best?

• Population• Components: strength,

balance, endurance, flexibility, walking

• Amount of supervision• If progressive• If modified during program• Attendance rate• Dose

_________

Sherrington, JAGS, 2008

Systematic review & meta-analysis of 44 studies

Results

Most effective programs:

• Challenged balance

• Used a high dose (50+ hrs)

• Did not include a walking program

Preventing Falls: What Works

www.cdc.gov/HomeandRecreationalSafety/Falls/preventfalls.htm

Effective Exercise Interventions

Study Components DoseBarnett, 2003 Balance, coordination, strength,

reaction time, aerobic capacity80+ hr

Campbell, 1997

Balance & strength, walking 78 hr

Li, 2005 Tai Chi 78 hr

Lord, 2003 Balance, strength, coordination, gait

96 hr

Rubenstein,

2000

Balance, strength, endurance, mobility

54 hr

Wolf, 1997 Tai Chi 88 hr

Challenges

• Achieving a sufficient exercise dose

• Motivating older adults to participate in exercise to prevent falls1

_________

Crombie, Age & Ageing, 2004

In Conclusion…

• Programs challenge balance

• Programs include 50+ hours of exercise

• Motivate older adults to participate

Exercise can reduce fall rates if:

Thank You!

jas2@cdc.gov