Intended for healthcare professionals

Clinical Review State of the Art Review

Prevention of falls in older people living in the community

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1419 (Published 28 April 2016) Cite this as: BMJ 2016;353:i1419

Exercise prescription is no mystery Re: Prevention of falls in older people living in the community

This State of the Art Review [1] is a welcome affirmation of the evidence on effective approaches to preventing falls in community-dwelling older people. Common and repetitive, falls can have major impact on the quality of life and disability experienced by older people. It is clear that tailored exercise integrated within a small basket of key evidence based interventions is the most effective approach to addressing this silent epidemic.

But at a practical level, we take issue with the review’s assertion that “the specific types and amount of exercise are still to be determined”. The specific elements of an effective exercise prescription were reported in 2011 in an in-depth review of the evidence [2]: a dose of at least 50 hours of challenging balance and progressive strength training, delivered by trained professionals. There is no mystery here.

In the UK, two specific programmes mentioned in the CDC Compendium [3] are commonplace - the Otago Exercise Programme (OEP) [4] and the FaME programme [5 & 6]. OEP and FaME were first implemented through a service in South West London in 2000, as reported in the BMJ [7]. A recent audit suggested that falls services nationally are employing appropriately trained professionals, but many services are not meeting the 50 hour effective prescription requirement. [8]

This review identifies key barriers encountered by a population level approach which resonate with the current UK situation: (a) short-term funding; (b) consistency and fidelity of delivery; (c) availability of providers; (d) clear protocols and quality assessments; (e) training and supervision of professionals; and (f) patient education. These can be addressed, but require system wide action.

All Clinical Commissioning Groups will have finalised plans to address local gaps in finance, quality of care, and health outcomes by the end of June. These Sustainability and Transformation Plans provide the opportunity to translate the potent potential of falls prevention research into local programmes that address avoidable disability and costs, at scale.

References:

[1] Vieira ER, Palmer RC, Chaves PHM. Prevention of falls in older people living in the community. BMJ 2016;353:i1419.

[2] Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. Exercise to
prevent falls in older adults: an updated meta-analysis and best practice
recommendations. NSW Public Health Bull 2011;23:78-83.

[3] Centers for Disease Control and Prevention. A CDC compendium of effective fall interventions: what works for community-dwelling older adults. Washington, US: CDC, 2015.

[4] Campbell AJ, Robertson MC, Gardener MM, Norton RN, Tilyard MW, Buchner DM. Randomised control trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997;315:1065-9.

[5] Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise - FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age and Ageing. 2005;34(6): 636-39.

[6] Iliffe S, Kendrick D, Morris R, Masud T, Gage H, Skelton D, et al. Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care. Health Tech Assess 2014;18(49).

[7] Simey P, Skelton D, Dinan S, Laventure R. Tailored exercise is key to preventing falls. British Medical Journal 2002; 325:1177.

[8] Royal College of Physicians. Older people's experience of therapeutic exercise as part of a falls prevention service. London: RCP, 2012.

Competing interests: Dawn Skelton is Director of Later Life Training, a not for profit provider of exercise training to health and fitness professionals

30 April 2016
Piers W Simey
Consultant in Public Health
Professor Dawn A Skelton, Professor in Ageing & Health, Glasgow Caledonian University; Professor Jim McManus, Director of Public Health, Hertfordshire County Council
Public Health Service (Postal Point CHO231), Hertfordshire County Council, County Hall, Pegs Lane, Hertford, SG13 8DQ