Randomised factorial trial of falls prevention among older people living in their own homes
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7356.128 (Published 20 July 2002) Cite this as: BMJ 2002;325:128
All rapid responses
On the basis of their comprehensive and well-controlled study, Day et
al., conclude that;
"The reduction in falls among participants receiving the exercise
intervention was associated with improved balance, most prominent on
completion of the exercise programme. However, the falls reduction in this
group may also have been mediated via social interaction or behavioural
change, or both of these, as a result of heightened awareness engendered
during the classes."
There is ample evidence to suggest that the reduction in falls
associated with exercise intervention programmes in the elderly may also
be mediated by improvements in reaction times, attentional control,
cognitive efficiency and emotional benefits.
Much of the physical and psychological decline associated with aging
is thought to be closely related to disuse atrophy or "hypokinetic
disease", terms used to describe a range of adverse somatic and cognitive
changes and functional losses produced by inactivity (Bortz, 1980).
Research has shown that aerobic exercise prevents, and may in fact
reverse, age-related losses associated with inactivity. Aerobic exercises
are those that require continuous and rhythmic use of large muscles for at
least 15 minutes on three or more occasions a week, and which increase
resting heart rate by at least 60% of heart rate reserve (DeVries, 1975).
Aerobic fitness training is accompanied by increased oxygen utilization,
indicating more efficient transport and delivery of oxygen to consumer
cells (deVries, 1975). Although many older adults are capable of doing
aerobic exercises such as walking, swimming, bicycling, or jogging at an
intensity to improve fitness level, only 10% or fewer actually exercise at
a level sufficient to maintain or improve cardiovascular fitness (Shepard,
1987).
Cross-sectional comparisons of simple and complex reaction times of
young and old adults reveal that individuals who are habitual exercisers
have response times significantly faster than those of sedentary
participants, and highly fit older people may be as fast as participants
who are 30 or 40 years younger (Spirduso et al., 1983, 1988; see Stones
and Kozma, 1996, for a review). Cognitive performance of individuals
whose life-styles include vigorous (aerobic) exercise also tends to be
superior to that of age-matched sedentary people. Thus, individuals who
are aerobically fit perform better than less-fit participants on tests
that measure fluid intelligence (Spirduso et al., 1990). These fitness-
related differences in response speed and cognition are probably not the
result of genetic predisposition for better CNS functioning. Longitudinal
studies, although few in number, have demonstrated improvements in
critical flicker fusion, reaction time, visuospatial reasoning, successive
cognitive processing, fluid intelligence, and memory (Dustman et al.,
1984; Ismail & El-Naggar, 1981; Hawkins et al., 1992).
For example, Hawkins et al. (1992) examined dual task performance of
both young and older adults using measures of attentional flexibility
(Keele & Hawkins, 1982), and time-sharing (Hawkins & Presson,
1986), both before and after 10 weeks of aerobic training. Hawkins et al.
noted that previous research has found consistent age-related decrements
in divided-attention performance. Hawkins et al. hypothesised that age-
related decrements in time-sharing and attentional flexibility could be
reduced as a function of improvements in aerobic fitness. It was found
that older adults showed substantially larger improvements on both tasks
than did non-exercise control participants.
An issue which has been raised is whether or not aerobic exercise or
improvement in cardiovascular functioning is necessary for reduction in
age-related psychological changes? To answer this question, the
mechanisms underlying the psychological benefits of exercise need to be
examined. There is evidence that exercise enhances the activity of
monoamines in the brain (Biddle & Fox, 1989; Spirduso, 1983).
Spirduso (1983) emphasized the decrease in neurochemical activity which
causes alterations in the aging central nervous system (CNS). Spirduso
(1983) pointed out the strong relationships between age, dopamine (DA),
and Parkinson's disease. Dopamine is decreased in both age and
Parkinson's disease, and Parkinson's disease patients are almost
exclusively over the age of 55. The relationship between age and slow
movement initiation (as in Parkinsonism) seems to be influenced by
physical condition so that the maintenance of high fitness can preserve
movement initiation speed.
Another possible physiological mechanism, especially emphasised for
the older population, is the increase in oxygen-transport capacity, blood
circulation, and energy supply to different parts of the body (including
the brain) as a result of exercise (Dustman et al., 1984; Ismail & El-
Naggar, 1981).
A further psychobiochemical mechanism which may explain the emotional
improvement following physical activity is release of endorphins by
exercise. Various endorphins can reduce pain and produce a sense of
euphoria. It has been suggested (Biddle & Fox, 1989; Morgan, 1985;
Spirduso, 1983) that exercise is associated with increased concentration
of plasma endorphins, and so is related to reduced depression and anxiety.
Alternative explanations for the psychological effects of exercise do
not regard aerobic exercise or improvement in cardiovascular functioning
as necessary. According to Powell (1974), physical activity may have a
stimulating effect upon the brain due to afferent stimulation from gross
muscular movement, primarily from proprioceptive feedback. Further,
volitional physical movement has an immensely interactive nervous
circuitry involving inputs from spinal, midbrain, and cortical levels of
the nervous system which take part in coordinated movement. The
involvement of the entire brain in physical activity may be an important
factor mediating a positive change in physical, mental and emotional state
of elderly persons (Ismail & El-Naggar, 1981) and in the reduction in
the incidence of falls (Day et al., 2002).
References:
Biddle, S.-J., & Fox, K.-R. (1989). Exercise and health psychology:
Emerging relationships. British Journal of Medical Psychology, 62(3), 205-
216.
Bortz, J., & Braune, P. (1980). The effects of daily newspapers on
their readers: Exemplary presentation of a study and its results. European
Journal of Social Psychology, 10(2), 165-193.
Day, L., Fildes B., Gordon, I., Fitzharris, M., Flamer, H. and Lord, S.
BMJ (2002). Randomised factorial trial of falls prevention among older
people living in their own homes, BMJ: 325: 128
DeVries, D.-L. (1975). The relationship of role expectations to faculty
behavior. Research in Higher Education, 3(2), 111-129.
Dustman, R.-E., & et al. (1984). Aerobic exercise training and
improved neuropsychological function of older individuals. Neurobiology of
Aging, 5(1), 35-42.
Hawkins, H.-L., & Presson, J. (1986). Auditory information processing.
In K. R. Boff & L. Kaufman (Eds.), Handbook of perception and human
performance (pp. 1-64). New York, NY, USA: John Wiley & Sons.
Hawkins, H.-L., Kramer, A.-F., & Capaldi, D. (1992). Aging, exercise,
and attention. Psychology and Aging, 7(4), 643-653.
Ismail, A. H., & El-Naggar, A.-M. (1981). Effect of exercise on
cognitive processing in adult men. Journal of Human Ergology, 10(1), 83-
91.
Morgan, W.-P. (1985). Psychogenic factors and exercise metabolism: A
review. Medicine and Science in Sports and Exercise, 17(3), 309-314.
Powell, R.-R. (1974). Psychological effects of exercise therapy upon
institutionalized geriatric mental patients. Journal of Gerontology,
29(2), 157-161.
Shepard, R. J., Berridge, M., Montelpare, W., Daniel, J.V., & Flowers
J. F. (1987). Exercise Compliance of elderly volunteers. Jounal of
Sports Medicine and Physical Fitness, 27, 410-418.
Spirduso, W. W. (1980). Physical fitness, aging, and psychomotor speed.
Journal of Gerontology, 35, 850-865.
Spirduso, W. W., MacCrae H. H., & Osborne, L. (1988). Exercise
effects on aged motor function. Annals of the New York Academy of
Sciences, 515, 363-375.
Spirduso, W.-W. (1983). Exercise and the aging brain. Research
Quarterly for Exercise and Sport, 54(2), 208-218.
Spirduso, W.-W., & MacRae, P.-G. (1990). Motor performance and aging.
In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of
aging (3rd ed.) (pp. 183-200). San Diego, CA, USA: Academic Press Inc.
Stones, M.-J., & Kozma, A. (1996). Activity, exercise, and behavior.
In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of
aging (4th ed.) (pp. 338-352). San Diego, CA, USA: Academic Press Inc.
Competing interests: No competing interests
Sirs,
Day L. et al. conclude correctly their interesting paper with the
statement that, in adults (Australian born) aged 70-84 years, group based
exercise was the most potent single intervention tested, and the reduction
in falls among this group seems to have been associated with improved
balance (1). This represents another clear evidence for the primary role
played by physical exercises programme also in aged men. At this point, I
would like to underscore , at least, three essential action mechanisms of
physical exercise, as a strategy improving health conditions in both
health and diseased people (e.g., involved by CAD). First of all, physical
exercises, properly programmed, increase Co Q10 production as well as
activate mitochondrial Q 10 cycle, e.g., in endothelial cells and
muscular – vascular smooth muscle and skeletal muscle – cells. Secondly,
physical exercises increase shear stress in microcirculatory bed, and
therefore ameliorate endothelial adhesion point distribuition, normalizing
nuclear stimulation by means of cytoskeleton proteins. Finally, well-
programmed physical exercises enhance blood-flow and consequently
regulate tissue pH, conditio sine qua non of physiological receptors
sensitivity to catecolamine, insulin, a.s.o. (2,3,4)
Sergio Stagnaro MD., Member NYAS.
1) Day L., Fildes B, et al.Randomised factorial trial of falls
prevention among older people living in their own homes. BMJ 2002;325:128
( 20 July ).
2) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: la manovra di
Ferrero-Marigo nella diagnosi clinica della iperinsulinemia-insulino
resistenza. Acta Med. Medit. 13, 125, 1997.
3) Stagnaro-Neri M., Stagnaro S., La “Costituzione Colelitiasica”: ICAEM-
a, Sindrome di Reaven variante e Ipotonia-Ipocinesia delle Vie biliari.
Epatol. 20, 239, 1993.
4) Stagnaro S.-Neri M., Stagnaro S., Sindrome di Reaven, classica e
variante, in evoluzione diabetica. Il ruolo della Carnitina nella
prevenzione del diabete mellito. Il Cuore. 6, 617, 1993.
Competing interests: No competing interests
Specific exercise is the key
The role of exercise in effective falls prevention has had a mixed
press. Profound conclusions have been drawn from research studies with
severe limitations, including failure to select fallers, brief
intervention periods and exercise of insufficient intensity to stimulate
improvement. Many were alarmed by a trial where fallers fell more often
after being encouraged to walk(1) - if the authors had prescribed the
balance, gait and strength exercises used in New Zealand(2) in advance of
walking, this unfortunate outcome could have been avoided. Today
scepticism about the true impact of exercise still remains among
professionals and decision-makers in the UK.
The study by Day and colleagues(3) is a welcome addition to the
literature countering this alarmist view. In the UK, the soon to be
published Falls Management Exercise (FaME) trial by Skelton and co-workers
found that women aged over 65 with a history of falls taking part in
prolonged specific group exercise decreased falls by 60%, and injuries due
to falls by 75%. Prescribed exercises included those used by Campbell and
co-workers(2), as well as dynamic endurance, balance training, floor
exercise and coping strategies after a fall. An accredited training
course is now available nationally which covers the specific exercises
used(4).
We felt that it was important to test the FaME findings outside the
research environment and so set up a falls and injury prevention exercise
service for community living fallers (average age 81 years) in London in
January 2000. Participants have significantly improved a number of known
functional risk factors for falls and injuries, in addition to
significantly enhancing their scores in the SF36 domains of social
contact, mental health and change in health. Improvement in functional
capacity is also directly relevant to quality of life. As one participant
put it: “I can walk upstairs now. I haven’t been able to walk upstairs for
four years. I do my exercises every day at home. I know it’s doing me
good.”
Primary Care Trusts and Social Services Departments are under
pressure to promote the independence of their older residents. They would
do well not to overlook the broad impact of tailored exercise in this
area.
Piers Simey physical activity lead
Wandsworth Primary Care Trust, The Wilson, Cranmer Road, Mitcham, Surrey
CR4 4TP. piers.simey@mswha.sthames.nhs.uk
Dawn Skelton senior research fellow
University College London Institute of Human Performance, Royal National
Orthopaedic Hospital, Stanmore, HA7 4LP
Susie Dinan clinical exercise practitioner and research fellow
Royal Free Hospital & University College School of Medicine, Pond
Street, London, NW3 2PF
Bob Laventure consultant older people
British Heart Foundation National Centre for Physical Activity and Health,
Loughborough University, Loughborough, Leicestershire, LE11 3TU
1 Ebrahim S, Thompson PW, Baskaran V, Evans K. Randomized placebo-
controlled trial of brisk walking in the prevention of post menopausal
osteoporosis. Age and Ageing 1997; 26:253-260.
2 Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW,
Buchner DM. Randomised controlled trial of a general practice programme
of home-based exercise to prevent falls in elderly women. BMJ 1997; 315:
1065-1069.
3 Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S.
Randomised factorial trial of falls prevention among older people living
in their own homes. BMJ 2002; 325: 128. (20 July)
4 Details of the Postural Stability Training module can be obtained
from East Midlands and Pennine Training (Tel: 0116 229 5512). Co-
developed by Dinan S, Skelton DA & a National Advisory Group. Funded
by the Department of Health.
Competing interests: No competing interests