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Older people who participate in year-long exercise programmes fall less and are less likely to be injured if they do fall. Exercise does not increase or decrease their risk of hospitalisation.
The people aged 60 or over (average age 73 years) who were included in this review took part in supervised training programmes. Typically, about half of people at this age can fall at least once a year. These programmes combined aerobic, strength and balance training, exercising at a moderate intensity for 50 minutes, two or three times per week.
Current guidance from NICE recommends strength and balance training for older people at risk of falling but doesn't specify the type or frequency of exercise. This review helps to identify what type of exercise programmes show benefits in the longer-term. It also alleviates concerns that exercise might be harmful for a general population too.
Why was this study needed?
Falls are common in older people and can result in injury, pain and death. About 30% of people aged 65 or over have a fall each year, increasing to 50% of people aged 80 or over. An estimated £2.3 billion is spent by the NHS per year on falls.
Exercise is recognised as being important for older adults’ health, and there is evidence that it can reduce falls. However, most of the available evidence looks at short- or medium-term exercise interventions, rather than long-term programmes. There is also a lack of evidence about the most effective form of exercise, in terms of type, intensity, frequency and length of session.
This study aimed to investigate long-term exercise interventions and the risk of falls, injuries, hospitalisation and death to resolve some of the uncertainties around long term programmes.
What did this study do?
This systematic review identified 46 randomised controlled trials (22,709 participants) comparing an exercise intervention for older people with a control group for at least one year. The mean age was 73.1 years. Most were living in the community, and some had mild dementia or heart disease.
Trials used aerobic, strength or balance training or a combination. They were either group-based supervised sessions or a mix of group-based and home-based unsupervised exercises. Only two trials were carried out in the UK; most were from the US and Europe.
Little information was given about the control group interventions, or how well participants adhered to their exercise programmes. Risk of bias was assessed for each trial, with the main risk being due to a lack of participant blinding that would have been difficult to reduce.
What did it find?
- Long-term exercise interventions decreased the risk of falls: 43.1% of the exercise group had a fall over the 12 month period, compared to 48.2% of the control group (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.79 to 0.98; 20 trials with 4,420 participants).
- Exercise also decreased the risk of having a fall that resulted in injury: 16.9% of the exercise group had injurious falls, compared to 20.6% of the control group (RR 0.74, 95% CI 0.62 to 0.88; 9 trials with 4,481 participants).
- There was a trend towards fewer fractures in the exercise group, but the difference was not statistically significant: 5.3% of people in the exercise group sustained a fracture, compared to 6.3% of controls (RR 0.84, 95% CI 0.71 to 1.00; 19 trials with 8,410 participants).
- Exercise had no effect on death or hospitalisation, neither increasing nor decreasing the risk of these outcomes: 7.1% of the exercise group died, compared to 7.9% of the control group (RR 0.96, 95% CI 0.85 to 1.09; 29 trials with 11,441 participants). Hospitalisations due to a fall occurred in 44.0% of the exercise group and 44.6% of the control group (RR 0.94, 95% CI 0.80 to 1.12; 12 trials with 5,639 participants).
What does current guidance say on this issue?
The NICE 2013 guideline on assessing risk and prevention of falls in older people recommends individually-prescribed muscle-strengthening and balance training for preventing falls. It says those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficiency.
The guideline does not specify details of the frequency, intensity, session duration or length of any exercise programme.
NICE reviewed this guideline in 2016 and decided to wait for further evidence before making any changes or more specific recommendations.
A recent Cochrane review on exercise for preventing falls in older people focusses on the different types of exercise in more detail (including shorter programmes) and comments on the role of balance, and functional exercises in particular.
What are the implications?
Older people can take part in exercise programmes without worrying that it may increase their risk of falling or chance of injuring themselves. This review adds to what we know by focusing on the programmes of regular exercise, including balance training, which is sustained over a year.
People with chronic conditions including heart disease or mild dementia should be encouraged to exercise.
The NHS web pages have exercise suggestions and workout videos of varying levels and duration suitable for older people. These range from chair Pilates to more intense strength and aerobic classes. There are also regimes for people with specific problems such as back pain, osteoporosis and arthritis.
Citation and Funding
de Souto Barreto P, Rolland Y, Vellas B, Maltais M. Association of long-term exercise training with risk of falls, fractures, hospitalizations, and mortality in older adults: a systematic review and meta-analysis. JAMA Intern Med. 2018; Dec 28. doi: 10.1001/jamainternmed.2018.5406. [Epub ahead of print].
No funding information was provided for this study.
Bibliography
NHS website. Exercise: physical activity guidelines for older adults. London: Department of Health and Social Care; 2016.
NHS website. Falls: prevention. London: Department of Health and Social Care; 2018.
NICE. Falls in older people: assessing risk and prevention. CG161. London: National Institute for Health and Care Excellence; 2013.
Sherrington C, Fairhall NJ, Wallbank GK et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;(1):CD012424.
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