The age composition of Australia's population is estimated to change considerably during the next 50 years, as the baby-boomers enter older adulthood. The number of people aged 65 years and over is projected to at least double by 2051,1 which will lead to a considerable increase in demand for health services. A large proportion of the care and services burden will be associated with fall related injury, unless effective preventive strategies are put in place.2 One in three people (living in the community) over the age of 65 years experience at least one fall each year,3 with over 30% suffering injuries requiring medical attention.4 By 2051, the total health cost attributable to fall related injury will increase almost three fold to $1375 million per annum and we will require 2500 additional hospital beds for fall injury treatment and 3320 additional nursing home places.1 The consequences of falls for the individual are also devastating, often leading to a downward spiraling effect, involving fear, reduced activity, loss of function and further risk of falling. However, many falls can be prevented. We need a team-based approach, with collaboration among health professionals and for exercise scientists to take a leading role.
Much of the risk of falling in older adults is due to the age-associated decline in motor and sensory functions. Starting in the mid-twenties, the human body begins a progressive loss of muscle mass, diminishing by 35–40% between the ages of 20 and 80 years.5 Muscular strength decreases by approximately half by the age of 80 years. Moreover, contraction speed is typically prolonged in the muscles of older people, likely due to the preferential atrophy of fast-twitch fibres,6 further impacting on motor function. A consequence of this atrophy, for example, is that older adults are slower to generate the required joint torques to successfully recover balance after tripping.7 Further affecting an older person's control of balance is sub-optimal sensory information, due to the age-associated decline in visual, vestibular and proprioceptive acuity, in addition to central integration processes.
The risk of injury during a fall incident is also increased in the elderly. Approximately 10–15% of older adults suffer a serious injury due to a fall and 5% of falls result in fractures, the most critical being femoral neck fractures. Bone fractures in older adults are largely explained by the loss of bone mass with age, adults lose bone at a rate of approximately 1% per year after the fourth or fifth decade, accelerated by menopause in women.8 The implications of fractures are serious and include impaired mobility, loss of independence and death. In the first few months after hip fracture, complication rates are as high as 45%, mortality rates are around 10%9 and many people never return to pre-fracture levels of functional ability.10 Equally alarming is the fact that half of the people who are unable to get up from the floor after a fall and lie unattended for an hour or more, die within the following 6 months.11
It is now clear that falls are not random events or an inevitable part of aging. Instead, falls can be predicted by poor performance in measures of balance, reaction time, lower limb muscular strength and proprioception. Together with a test of visual contrast sensitivity, these measures can predict, with an accuracy of 75%, whether an individual will fall in the following 12 months.12
Exercise has a major role to play in modifying key falls risk factors and preventing falls among older adults. Research has shown that older adults, participating in exercise programs, can improve reaction time, walking speed, muscular strength,13 and balance.14 Moreover, there have now been many randomised controlled trials which have shown statistically and clinically significant reductions in falls following exercise interventions.15 One such trial involved 163 community-dwelling older adults at risk of falls, who were randomly allocated into either exercise or control groups. The exercise intervention involved group sessions with a focus on balance training for 1
h, once per week, with additional home exercises for four terms spanning 1 year.16 A 40% reduction in falls was reported for the exercise group, compared to the control group, in the year following the intervention. A home program of balance and strength exercise can also be very effective in preventing falls.17 Of course, such programs may also provide additional benefits for cardiovascular health, bone and joint health, reducing the incidence of diabetes and stroke, maintenance of independence and psychological well-being.
Federal and state falls prevention initiatives include recommendations for exercise to prevent falls in older adults. Furthermore, clinicians have long been recommending exercise for older adults as a preventative strategy against falls. Health promotion initiatives for falls prevention are important in their wide-reaching education to create an attitudinal change towards exercise, which may have an impact on reducing falls in future years. However, for a more immediate reduction in the incidence of falls, the evidence suggests that there is a need for individually prescribed and supervised exercises provided by a trained exercise specialist.18 This role has been effectively carried out by physiotherapists and other health professionals, but in limited supply. With our ageing population and the mounting evidence for the need of exercise programs for falls prevention, there is a much larger work capacity required to fill this void in the prevention of falls. Particularly since our current health system is already strained, exercise scientists need to come on board in a partnership effort with allied health professionals, to deliver necessary interventions.
An important role exists for exercise scientists in promoting and managing the health of older adults and, together with the wider fitness industry, have the potential to make a significant contribution to falls prevention. In fact, this should be a major professional activity, where many exercise science graduates establish a career. Currently, this is not the case, and unfortunately many graduates envisage a lack of employment options and move into unrelated career paths. Paradoxically, exercise science students are well educated to work in elite sport, where there are few jobs. Students need to be aware of the scope for career development with older adult populations. University courses should reflect the need in the community. Units that focus on the physiology of ageing and exercise prescription for older adults, together with practicum placements working with older adults will provide the necessary information and exposure to realistic work options.
Exercise scientists can utilise their knowledge in physiology, biomechanics and exercise prescription and take a lead role in providing exercise services for older adults, and importantly, for falls prevention. In designing and implementing exercise interventions, certain key issues need to be addressed by the exercise scientist.
•Establish dependable lines of communication with general or specialist medical practitioners. This will involve a flow of information in both directions, to ensure appropriate referral, an understanding of the value of the exercise, client needs and limitations, and common goals.
•Establish dependable lines of communication with physiotherapists, nurses, occupational therapists and other rehabilitation team members. Many older people and younger people with acute or chronic disability require ongoing exercise after a period of intensive rehabilitation. Exercise scientists can play an important role in providing this in conjunction with other team members.
•Consideration of the physiological consequences of ageing, while also taking into account factors affecting individual's rate of biological ageing (i.e., general health, physical activity levels, previous medical conditions). A thorough health check and fitness assessment should be conducted, and a medical history established by the exercise scientist, to determine each individual's capabilities and contraindications for exercise (see19 for ACMS guidelines). Some people may require additional consultation by a physiotherapist or medical specialist. •Individual prescription of exercise to address the specific falls risk factors of each participant.
•Translating findings from falls research into practice. For example most general exercise programs focus on quadriceps strength, but biomechanical studies tell us that hip and ankle extensors are more important in terms of walking and recovering from a trip.7, 20 Previous clinical trials of exercise suggest that a program for falls prevention should incorporate: balance exercises; exercises conducted in weight-bearing positions; functional activities; an additional component of general fitness/endurance training; and a component of moderate intensity resistance training.15 •Application of the training principles of intensity, duration and frequency, as appropriate to the individual's capabilities and for sufficient gains. The exercise must be challenging yet safe.
•Regular assessments and appropriate adjustment of the exercise prescription to ensure the program continues to produce results.
•It is particularly important to consider motivational factors and barriers to participation. Facilitation of group socialisation and enjoyment during exercise, and limiting barriers to participation, will assist with compliance.
•Continued promotion of the importance of exercise for falls prevention.
Some exercise programs for falls prevention currently exist for older adults, yet few meet the important needs for falls prevention. An example of a program that involves a line of communication between medical practitioners and the exercise scientist is the General Practitioners Association Circuit and Group Exercise, in Geelong. This program is implemented across several community recreation centres, offering individual assessment and exercise prescription following a medical clearance from client's General Practitioners. One centre sees 250 older adults per week, classes are full and compliance is excellent. Programs such as this also provide a good opportunity for fitness centres to maximise gym use during off-peak morning and afternoon periods. Exercise scientists need to develop proposals, promote the need for falls prevention exercise programs and proudly assert the skills they have to provide this much needed service for the health of older people.
Falls in the elderly are a major public health problem and with the advancing age of the Australian population, will place increasing demands on our already strained health services. To prevent falls, everyone must recognise the need and subsequently commit to maintaining good health and fitness throughout life. Producing this shift in behaviour will take many years and more still to have an impact on the incidence of falls. To address the immediate issue of falls, we need individualised interventions, targeted at specific falls risk factors and appropriate to the needs of older people. Exercise has great potential to modify many risk factors for falls in older adults. It requires the specialist knowledge of human physiology, biomechanics and exercise prescription that may be offered by graduates of exercise science degrees.
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