# Exercise as it relates to Disease/Improving mobility in older people through exercise

A critical analysis of 'Effects of a fall prevention program including exercise on mobility and falls in frail older people living in residential aged care facilities' by Jensen J, Nyberg L, Rosendahl E, Gustafson Y, Lundin-Olsson L (2004).

## Background to research

Falls are most common within the elderly population due to their likelihood of developing frailty and being at greater risk of acquiring cognitive and physical health conditions contributing to reduced mobility. A greater incidence of falls places the elderly population at higher risk of sustaining serious injuries, such as hip fractures, causing reduced independence and quality of life. Falls are categorised as the leading cause of injury related deaths for those aged over 70.
This establishes the importance of developing an appropriate and reliable falls prevention program which targets mobility and considers the impact of varying levels of cognition. Furthermore, investigating both the short and long-term effects of exercise interventions fills a gap in existing knowledge developed from previous studies. Research into how the incidence of falls can be lessened by modifiable risk factors such as exercise is critical to reduce the burden on the health and wellbeing of the elderly population.

## Where is the research from?

This article was published in the journal 'Ageing- Clinical and Experimental Research', a multidisciplinary forum on the progressive field of geriatrics and gerontology. The journal is published bimonthly with new and emerging papers promoting its increasing popularity and reputation.
The primary author, Jane Jensen, has been involved in 6 research articles through Umeå University, all of which relate to the field of falls and mobility in the aged population. This indicates a moderate level of experience, however, does not give her a high standard reputation in comparison to other well-established researchers in the field. All co-authors have involvement in other research in a similar field. This increases the depth of knowledge and experience within the study.

## What kind of research was conducted?

This study was a randomised control trial, which is often considered as the 'gold standard' of research designs due to its ability to identify a cause and effect relationship when conducted appropriately. 187 aged-care residents across nine facilities in Umeå, Sweden participated, all of which had physical and/or cognitive impairments and were considered to be at risk of falling.
Half of the participants were randomly assigned to an intervention group which participated in an 11-week program targeting general risk factors (educating staff in fall prevention and modifying the physical environment) and resident-specific risk factors (exercise program, supplying and repairing aids, reviewing drug regimens, post-fall problem-solving conferences and providing free hip protectors).
All participants underwent initial physical and psychological testing to determine baseline levels of cognition, mobility and falls risk, including:
* Mini-Mental State Examination (MMSE)
* Mobility Interaction Fall Chart, Functional Ambulation Categories (FAC)
* Self-paced gait speed
* Berg Balance Scale
* Step height
Physical tests were reassessed following the intervention (short-term) and after nine months (long-term). The number of participants are likely to significantly reduce throughout a nine-month period within an elderly population (i.e. from death, serious injury, or relocating), highlighting a difficultly in conducting a long-term trial within a frail population.
Characteristics of this research:
* Study design and length of the intervention provides foundation for a quality trial
* The likelihood of finding a definitive cause and effect may be affected by the number of independent variables being altered in addition to an exercise program alone
* High number of variables being assessed at baseline and follow ups may impact the reliability of results in subsequent assessments with the potential of fatigue occurring
* Potential bias in the follow up assessments with all conducted by the same staff, this reduces the presence of blinding due to assessors being exposed to the participants of the intervention group

## Basic Results

Evaluation of the intervention was planned to be conducted following the 11-week intervention as a short-term evaluation, and nine months following the beginning of the intervention as a long-term evaluation.
Key significant results in the short-term evaluation included:
* Percentage of participants stepping over 5 and 10cm increased in the intervention group and decreased in control group, with greater step height reducing foot drag which increases falls risk
* Percentage of those in the intervention group independently ambulating was maintained in the intervention group, but decreased in the control group
* Maximum gait speed was maintained in the intervention group, but significantly reduced in the control group, slow gait speed significantly increases the risk of falls
* Within the 11 weeks, 5 participants in the control group had lost the ability to walk; no participants in the intervention group lost this ability
The long-term effects of the trial included:
* Participants of the intervention group had slight improvements in the ability to ambulate independently, while the control group continued to lose this ability
* Significantly more participants in the control group lost the ability to walk 10 metres (15 in control group, 3 in intervention group)
* Maximum gait speed in the intervention group was relatively unchanged from baseline, while a significant reduction occurred in the control group.
Despite improvements occurring in mobility as a result of exercise in the intervention group, when this was related to the number of residents who had fallen in a three-categorical index of improved mobility, no statistically significant differences were found between the intervention and control groups. This may have been impacted by how participants were categorised and the drop-out rate within each group.

## Conclusions taken from research

The key conclusions made by the authors were that overall, the implementation of an exercise program within aged care residents with varying levels of cognition had a preservative effect on mobility, and positive effects on gait speed and step height in both the short and long-term.
Although results were not significantly translated to reducing the risk of falling, from a clinical point of view, improvements and maintenance of mobility will have a positive impact on reducing the likelihood of falling. However, specifications on the type and duration of exercise in the intervention program have not been made, increasing the difficulty of forming recommendations for the general public.
This research is thorough in assessing multiple components of mobility, however the complexity in its methodologies may have impacted the reliability of results within an elderly population. Moreover, the long-term impacts of exercise, while crucial, is difficult to ultimately understand with severe injury/illness or death being prominent amongst the aged population.

## Practical Advice

Participating in physical activity in addition to receiving adequate support, information and physical aids, is critical in preserving mobility and ambulation in order to maintain independence for as long as possible throughout ageing. Exercise of any form should be maintained throughout the lifespan to preserve mobility as well as reducing the risk of many health conditions. However, the risk of injury when participating in exercise in older age should be considered when constructing a program with adequate assistance and supervision provided to maximise safety and promote confidence.

## Further information/resources

The following websites provide useful information on the risks of falling and benefits of exercise:
Benefits of being active for Older Australians
WHO fact sheet- Falls
Exercise Plan for Seniors
Physical Activity Guidelines for Older Adults
Australia & New Zealand Fall Prevention Society

## References

* 1 2 3 4 Jensen J, Nyberg L, Rosendahl E, Gustafson Y, Lundin-Olsson L. Effects of a fall prevention program including exercise on mobility and falls in frail older people living in residential care facilities. Aging clinical and experimental research. 2004;16(4):283-92.
* ↑ Berg RL, Cassells JS. Falls in older persons: risk factors and prevention. The second fifty years: Promoting health and preventing disability: National Academies Press (US); 1992.
* ↑ James SL, Lucchesi LR, Bisignano C, Castle CD, Dingels ZV, Fox JT, et al. The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017. Injury prevention. 2020;26(Supp 1):i3-i11.
* ↑ Akobeng AK. Understanding randomised controlled trials. Archives of disease in childhood. 2005;90(8):840-4.
* ↑ Dyer AH, Lawlor B, Kennelly SP. Gait speed, cognition and falls in people living with mild-to-moderate Alzheimer disease: data from NILVAD. BMC geriatrics. 2020;20(1):1-10.
* ↑ Chodzko-Zajko WJ, Proctor DN, Singh MAF, Minson CT, Nigg CR, Salem GJ, et al. Exercise and physical activity for older adults. Medicine & science in sports & exercise. 2009;41(7):1510-30.