Transcript Exercise approaches for the prevention of frailty

Professor Keith Hill,
School of Physiotherapy
[email protected]
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
Gippsland Workshop: September 2014
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How effective is exercise in reducing falls in
older people (focus on people without
dementia)
Different options for exercise to reduce falls
in older people
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Factors to consider in exercise prescription
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Addressing barriers to exercise participation
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Exercise
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various forms of exercise
strong evidence
of effectiveness
of training in
older people to
improve specific
specificity of training
risk factor
other health benefits of exercise
programs
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balance
strength
cardiovascular fitness
flexibility
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There is good research (at least one randomised trial)
evidence that a number of single interventions can
reduce falls / injuries:
 exercise (home exercise; tai chi, group exercise)
 cataract extraction / change multifocal glasses to 2 sets of
glasses
 psychotropic medication withdrawal / medication review
 home visits by Occupational Therapists
 improved post hospital discharge follow-up
 approaches to support client uptake in recommended
interventions
 vitamin D and calcium supplementation (in low vit D cases)
 cardiac pacemaker for carotid sinus hypersensitivity
 foot exercise, footwear and orthoses
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multiple interventions based on a falls risk assessment
have also been shown to be effective (including in high
falls risk groups, eg older fallers presenting to ED)
COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)
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Randomly selected
sample (>5,000
participants, 61%
response rate)
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Group exercise programs
Home exercise programs
(often prescribed by a
physiotherapist
Tai Chi- (note: different
types of Tai Chi may have
different effects)
Foot and ankle exercise
as part of podiatric multifaceted program (Spink et
al, 2011)
Cochrane review: Gillespie et al 2012 (159 trials with 79,193 participants)
54 RCTs (all settings, though most in community)
Sherrington et al 2011
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Exercise interventions
 Sample with disabling foot
pain and increased falls
risk
 Intervention=foot & ankle
exercise, footwear subsidy,
and orthoses provision
 Intervention group had
36% fewer falls, p<0.05
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
Spink M et al,, .BMJ. 2011 Jun 16;342:
Exercise interventions
 At risk sample – falls or
injurious fall in past 12/12
 Intervention=Lifestyle
Integrated Functional
Exercise
 Compared LiFE program
vs structured exercise
program vs control
 31% reduction in falls
(LiFE vs control, p<0.05)
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
Clemson L,, et al .BMJ. 2012 Aug 7;345:e4547
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Exercise parks for
older people (Finland:
Lappset)
recently commenced
study at Victoria
University
http://www.lappset.com/global/en/
Pro_Play/The_Elderly_.iw3
Tai chi for arthritis – Sun style
24 form Beijing style – Yang style
Very frail/
High falls risk
Healthy older
people
CONTINUUM OF BALANCE IMPAIRMENT
Otago Exercise Program
“Otago Plus” – incl VHI kit
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Safety concerns
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Frail / high falls risk
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Limited self - discipline
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Impaired memory (potential role of
carer)
for balance exercises to be effective, they
need to challenge the balance system safely
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Classification from Merom et al, Prev Med, 2012
cannot include hand
support
needs to target
balance deficits
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safety (boxed in)
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functional vs non
functional
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dynamic in
preference to static
STATIC TASKS
Dual /
multiple task
Sensory manipulation
Single task
Closed environment
No sensory
manipulation
Low level
of challenge
High level
of challenge
Open
environment
Visual
Wide fixation
BOS
Lack of
visual fixation
Narrow Base of
Support (BOS)
DYNAMIC TASKS
Bernhardt & Hill – 2005
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goal oriented
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safety
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intermittent reappraisal of
performance / feedback
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regular practice / repetition
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functional context
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fun / enjoyable / social
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Based on
◦ assessment findings (eg functional tests)
◦ circumstances of falls
◦ patient interests and activities
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Observe performance of selected exercise for safety and
accurate performance
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Written instructions and contact number
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Start off with low dosage and intensity relevant to
assessment findings
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Encourage fitting into daily routine
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Intermittent review and modification as required
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12 week weight bearing (home based) exercise
program (3 times / week) vs seated resistance
exercise vs social visit
Loss of up to 50% of balance gains in the
subsequent 12 weeks after ceasing exercise
Vogler et al, 2012, Arch Phys Med Rehabil; 93: 1685-91
(Nyman and Victor, Age and Ageing, 2012)
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Reviewed 99 randomised trial in 2009 Cochrane
review (falls prevention in the community)
Adherence rates (n = 69) were:
≥80% for vitamin D/calcium supplementation;
≥70% for walking and class-based exercise;
52% for individually targeted exercise;
approximately 60-70% for fluid/nutrition therapy and
interventions to increase knowledge;
◦ 58-59% for home modifications;
◦ Adherence to multifactorial interventions was generally
≥75% but ranged 28-95% for individual components.
Home-exercises on average 11 times per month
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CONCLUSIONS:
Using median rates for recruitment (70%), attrition (10%) and adherence (80%),
we estimate that, at 12 months, on average half of community-dwelling older
people are likely to be adhering to falls prevention interventions in clinical trials.
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chronic conditions (eg arthritis)
◦ perception that exercise will aggravate pain
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access (cost / transport)
no-one to exercise with
perception that exercise is not appropriate /
beneficial for older people
lack of awareness of
◦ benefits
◦ available options (locally)
Hill and Murray, 2004. Physical activity & falls prevention (chapter in
book edited by Morris and Schoo)
Anne-Marie Hill et al, 2011, The Gerontologist
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Generally low exercise participation levels
in older people - need for approaches to
improve participation
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Exercise approaches can achieve positive fall related outcomes
for older people, across the falls risk / frailty continuum
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Strong research evidence that falls can be reduced through
exercise interventions, especially
 those with a balance component
 those with >50 hours dosage
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Most research has excluded people with dementia
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Need to consider balance ability, safety and patient preference
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Major issue of uptake and longer term adherence