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Study Overview
Objective. To evaluate the association between long-term exercise interventions (duration ≥ 1 year) and risks of falls, injurious falls, multiple falls, fractures, hospitalization, and mortality in older adults.
Design. A systematic review of randomized controlled trials (RCTs) with preplanned meta-analysis was conducted to investigate the association between long-term exercise interventions and falls and fall-related adverse outcomes in adults older than 60 years. A literature search using electronic databases, including PubMed, Cochrane Central Register of Controlled Trials, SportDiscus, PsychInfo, and Ageline, was performed between February 20 and March 5, 2018. Studies selected were RCTs with exercise duration of 1 year or longer, where effects of exercise intervention were compared with a comparator group of participants aged 60 years or older. Articles were independently screened, abstracted, and assessed for risk of bias by 2 raters, who resolved divergences in data extraction and synthesis via in-person meetings.
Setting and participants. A total of 46 studies (22,709 participants; median of 203 participants per study) were included in the review and 40 studies (21,868 participants) were included in the meta-analysis. The participants’ mean age was 73.1 ± 7.1 years, and 66.3% (15,054 participants) were women. Studies were mostly conducted in Europe (n = 15), North America (n = 13), and Oceania (n = 10). Multicomponent training involving multiple exercises (eg, aerobic, strength and balance; 29 RCTs) was the most common intervention modality, followed by aerobic (8 RCTs) and strength (5 RCTs) training. Exercise interventions had a mean frequency of 3 times/week, with each session lasting approximately 50 minutes, and were administered at a moderate intensity. The average compliance rate with exercise training was 65%. Comparator groups were often active controls that ranged from attention controls to more intensive interventions.
Main outcome measures. The 6 binary outcomes investigated were fallers who fell at least once, multiple times, or at least twice; fractures; hospitalization; and mortality. Estimates of outcomes were combined using risk ratios (RRs) using DerSimonian and Laird’s random-effects model (Mantel-Haenszel method). Heterogeneity was evaluated using I2 statistics, and trials with low rates of compliance (< 30%) with exercise intervention or high attrition (> 40%) were excluded in primary analyses.
Main results. Exercise training significantly reduced the risk of falls by 12% (n = 20 RCTs; 4420 participants; RR, 0.88; 95% confidence interval [CI], 0.79-0.98) and injurious falls by 26% (9 RCTs; 4481 participants; RR, 0.74; 95% CI, 0.62-0.88), and reduced the risk of fractures by 16% (19 RCTs; 8410 participants; RR, 0.84; 95% CI, 0.71-1.00; P = 0.05). Exercise training did not decrease the risk of multiple falls (13 RCTs; 3060 participants; RR, 0.86; 95% CI, 0.68-1.08), hospitalization (12 RCTs; 5639 participants; RR 0.94; 95% CI, 0.80-1.12), or mortality (29 RCTs; 11,441 participants; RR 0.96; 95% CI, 0.85-1.09). Sensitivity analyses yielded similar results, with the exception of the fixed-effect meta-analysis for the risk of fracture that showed a significant effect of long-term exercise training (RR, 0.84; 95% CI, 0.70-1.00; P = 0.047). Meta-regression analysis on mortality and falls suggested that exercise frequency between 2 and 3 times per week was optimal and beneficial.
Conclusion. Long-term exercise training of 1 year or longer in duration is associated with a reduction in falls, injurious falls, and fractures in older adults. Moreover, moderate intensity, multicomponent exercise training performed 2 to 3 times weekly is likely safe and effective in this vulnerable population.
Commentary
Falls are exceedingly common (1 in 3 older Americans fall each year) and are the leading cause of fatal and nonfatal injuries in persons over the age of 65 years.1,2 While fall prevention is a public health priority and a topic of interest in many research studies, there are important gaps in knowledge regarding optimal strategies to prevent falls and fall-related injuries in this high-risk population. The study reported by de Souto Barreto and colleagues provides new insights to address several of these gaps and may have a significant impact on the clinical practice of fall prevention in geriatric medicine.
Studies show that a single exercise intervention of short- to medium-term duration can prevent falls in community-dwelling older adults.3 However, the effects of long-term exercise training (ie, intervention lasting longer than a year) on fall prevention in this population is less well characterized. This study is the first meta-analysis that aimed to evaluate the potential beneficial impact of long-term exercise training on falls and adverse fall-related outcomes in adults ≥ 60 years of age who are prone to falls. The study’s findings indicate that long-term exercise training reduces the risk of falling by 12%, injurious falls by 26%, and factures by 16%. These results are important in that they add compelling evidence that exercise training of any duration can reduce falls and some fall-related adverse outcomes. Furthermore, the positive effects of long-term exercise training appear to mitigate some of the fatal and nonfatal injuries attributable to falls—the leading cause of such injuries in older adults.
The modality (type) and dose (frequency) of exercise training are important components of “exercise prescription” for older adults. However, there is a lack of research evidence to help clearly define these exercise parameters to better guide development of consensus exercise recommendations for older patients. This gap in knowledge limits the clinicians’ ability to recommend evidence-based treatment regimens to older adults who are at higher risk for falls. Moreover, although exercise programs are rarely associated with serious adverse events, recent findings from the Lifestyle Interventions and Independence for Elders (LIFE) study found a modest and nonstatistically significant association between long-term, moderate-intensity physical activity programs and an increase in hospitalizations and mortality in older adults.4,5 Taken together, these gaps in knowledge highlight the urgent need to better understand the optimal methods for administering exercise programs in older adults as well as the need for critical appraisals of the benefits and harms associated with long-term exercise training in this vulnerable population.
The results reported by de Souto Barreto and colleagues helped to address these questions. In this study, the authors found that long-term multicomponent training, particularly moderate intensity with balance exercises performed 2 to 3 times a week, appears to be a safe and effective intervention for reducing falls and injurious falls in older adults. Importantly, this type of long-term exercise regimen does not increase hospitalization and mortality, and thus supports the notion that exercise therapy is safe in older adults. Therefore, information gained from this meta-analysis should help to guide clinicians to devise a patient-centered exercise prescription for fall prevention.
The current study was well designed and has a number of strengths. The design of the systematic review and meta-analysis allowed aggregation of data from multiple trials, resulting in a more robust point estimate to evaluate the effects of long-term exercise training on falls and fall-related outcomes that otherwise cannot be achieved with individual trials. In addition, the emphasis on long-term exercise training in older adults in the setting of falls and adverse fall-related outcomes addresses a key area of research that currently lacks a sufficient evidence base. There are also several limitations in this study, primarily due to the nature of its meta-analysis design. For instance, the study populations included in the analysis are highly heterogeneous and range from those with dementia to healthy participants. In addition, long-term exercise training, defined as a duration ≥ 1 year, was arbitrarily established as the minimum period of intervention. Thus, potential important studies that include interventions of significant duration, but less than 1 year, may not have been captured in this analysis.
Applications for Clinical Practice
Falls in older adults are common and may lead to devastating health consequences. The implementation of a long-term, multicomponent, moderate-intensity exercise regimen performed 2 to 3 times weekly can reduce falls and injurious falls in older adults.
—Fred Ko, MD, MS
1. Schiller JS, Kramarow EA, Dey AN. Fall injury episodes among noninstitutionalized older adults: United States, 2001-2003. Adv Data. 2007(392);1-16.
2. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50:116-119.
3. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51:1750-1758.
4. Liu CJ, Latham, NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev. 2009;CD002759.
5. Pahor M, Guralnik JM, Ambrosius WT, et al. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial. JAMA. 2014;311:2387-2396.
Study Overview
Objective. To evaluate the association between long-term exercise interventions (duration ≥ 1 year) and risks of falls, injurious falls, multiple falls, fractures, hospitalization, and mortality in older adults.
Design. A systematic review of randomized controlled trials (RCTs) with preplanned meta-analysis was conducted to investigate the association between long-term exercise interventions and falls and fall-related adverse outcomes in adults older than 60 years. A literature search using electronic databases, including PubMed, Cochrane Central Register of Controlled Trials, SportDiscus, PsychInfo, and Ageline, was performed between February 20 and March 5, 2018. Studies selected were RCTs with exercise duration of 1 year or longer, where effects of exercise intervention were compared with a comparator group of participants aged 60 years or older. Articles were independently screened, abstracted, and assessed for risk of bias by 2 raters, who resolved divergences in data extraction and synthesis via in-person meetings.
Setting and participants. A total of 46 studies (22,709 participants; median of 203 participants per study) were included in the review and 40 studies (21,868 participants) were included in the meta-analysis. The participants’ mean age was 73.1 ± 7.1 years, and 66.3% (15,054 participants) were women. Studies were mostly conducted in Europe (n = 15), North America (n = 13), and Oceania (n = 10). Multicomponent training involving multiple exercises (eg, aerobic, strength and balance; 29 RCTs) was the most common intervention modality, followed by aerobic (8 RCTs) and strength (5 RCTs) training. Exercise interventions had a mean frequency of 3 times/week, with each session lasting approximately 50 minutes, and were administered at a moderate intensity. The average compliance rate with exercise training was 65%. Comparator groups were often active controls that ranged from attention controls to more intensive interventions.
Main outcome measures. The 6 binary outcomes investigated were fallers who fell at least once, multiple times, or at least twice; fractures; hospitalization; and mortality. Estimates of outcomes were combined using risk ratios (RRs) using DerSimonian and Laird’s random-effects model (Mantel-Haenszel method). Heterogeneity was evaluated using I2 statistics, and trials with low rates of compliance (< 30%) with exercise intervention or high attrition (> 40%) were excluded in primary analyses.
Main results. Exercise training significantly reduced the risk of falls by 12% (n = 20 RCTs; 4420 participants; RR, 0.88; 95% confidence interval [CI], 0.79-0.98) and injurious falls by 26% (9 RCTs; 4481 participants; RR, 0.74; 95% CI, 0.62-0.88), and reduced the risk of fractures by 16% (19 RCTs; 8410 participants; RR, 0.84; 95% CI, 0.71-1.00; P = 0.05). Exercise training did not decrease the risk of multiple falls (13 RCTs; 3060 participants; RR, 0.86; 95% CI, 0.68-1.08), hospitalization (12 RCTs; 5639 participants; RR 0.94; 95% CI, 0.80-1.12), or mortality (29 RCTs; 11,441 participants; RR 0.96; 95% CI, 0.85-1.09). Sensitivity analyses yielded similar results, with the exception of the fixed-effect meta-analysis for the risk of fracture that showed a significant effect of long-term exercise training (RR, 0.84; 95% CI, 0.70-1.00; P = 0.047). Meta-regression analysis on mortality and falls suggested that exercise frequency between 2 and 3 times per week was optimal and beneficial.
Conclusion. Long-term exercise training of 1 year or longer in duration is associated with a reduction in falls, injurious falls, and fractures in older adults. Moreover, moderate intensity, multicomponent exercise training performed 2 to 3 times weekly is likely safe and effective in this vulnerable population.
Commentary
Falls are exceedingly common (1 in 3 older Americans fall each year) and are the leading cause of fatal and nonfatal injuries in persons over the age of 65 years.1,2 While fall prevention is a public health priority and a topic of interest in many research studies, there are important gaps in knowledge regarding optimal strategies to prevent falls and fall-related injuries in this high-risk population. The study reported by de Souto Barreto and colleagues provides new insights to address several of these gaps and may have a significant impact on the clinical practice of fall prevention in geriatric medicine.
Studies show that a single exercise intervention of short- to medium-term duration can prevent falls in community-dwelling older adults.3 However, the effects of long-term exercise training (ie, intervention lasting longer than a year) on fall prevention in this population is less well characterized. This study is the first meta-analysis that aimed to evaluate the potential beneficial impact of long-term exercise training on falls and adverse fall-related outcomes in adults ≥ 60 years of age who are prone to falls. The study’s findings indicate that long-term exercise training reduces the risk of falling by 12%, injurious falls by 26%, and factures by 16%. These results are important in that they add compelling evidence that exercise training of any duration can reduce falls and some fall-related adverse outcomes. Furthermore, the positive effects of long-term exercise training appear to mitigate some of the fatal and nonfatal injuries attributable to falls—the leading cause of such injuries in older adults.
The modality (type) and dose (frequency) of exercise training are important components of “exercise prescription” for older adults. However, there is a lack of research evidence to help clearly define these exercise parameters to better guide development of consensus exercise recommendations for older patients. This gap in knowledge limits the clinicians’ ability to recommend evidence-based treatment regimens to older adults who are at higher risk for falls. Moreover, although exercise programs are rarely associated with serious adverse events, recent findings from the Lifestyle Interventions and Independence for Elders (LIFE) study found a modest and nonstatistically significant association between long-term, moderate-intensity physical activity programs and an increase in hospitalizations and mortality in older adults.4,5 Taken together, these gaps in knowledge highlight the urgent need to better understand the optimal methods for administering exercise programs in older adults as well as the need for critical appraisals of the benefits and harms associated with long-term exercise training in this vulnerable population.
The results reported by de Souto Barreto and colleagues helped to address these questions. In this study, the authors found that long-term multicomponent training, particularly moderate intensity with balance exercises performed 2 to 3 times a week, appears to be a safe and effective intervention for reducing falls and injurious falls in older adults. Importantly, this type of long-term exercise regimen does not increase hospitalization and mortality, and thus supports the notion that exercise therapy is safe in older adults. Therefore, information gained from this meta-analysis should help to guide clinicians to devise a patient-centered exercise prescription for fall prevention.
The current study was well designed and has a number of strengths. The design of the systematic review and meta-analysis allowed aggregation of data from multiple trials, resulting in a more robust point estimate to evaluate the effects of long-term exercise training on falls and fall-related outcomes that otherwise cannot be achieved with individual trials. In addition, the emphasis on long-term exercise training in older adults in the setting of falls and adverse fall-related outcomes addresses a key area of research that currently lacks a sufficient evidence base. There are also several limitations in this study, primarily due to the nature of its meta-analysis design. For instance, the study populations included in the analysis are highly heterogeneous and range from those with dementia to healthy participants. In addition, long-term exercise training, defined as a duration ≥ 1 year, was arbitrarily established as the minimum period of intervention. Thus, potential important studies that include interventions of significant duration, but less than 1 year, may not have been captured in this analysis.
Applications for Clinical Practice
Falls in older adults are common and may lead to devastating health consequences. The implementation of a long-term, multicomponent, moderate-intensity exercise regimen performed 2 to 3 times weekly can reduce falls and injurious falls in older adults.
—Fred Ko, MD, MS
Study Overview
Objective. To evaluate the association between long-term exercise interventions (duration ≥ 1 year) and risks of falls, injurious falls, multiple falls, fractures, hospitalization, and mortality in older adults.
Design. A systematic review of randomized controlled trials (RCTs) with preplanned meta-analysis was conducted to investigate the association between long-term exercise interventions and falls and fall-related adverse outcomes in adults older than 60 years. A literature search using electronic databases, including PubMed, Cochrane Central Register of Controlled Trials, SportDiscus, PsychInfo, and Ageline, was performed between February 20 and March 5, 2018. Studies selected were RCTs with exercise duration of 1 year or longer, where effects of exercise intervention were compared with a comparator group of participants aged 60 years or older. Articles were independently screened, abstracted, and assessed for risk of bias by 2 raters, who resolved divergences in data extraction and synthesis via in-person meetings.
Setting and participants. A total of 46 studies (22,709 participants; median of 203 participants per study) were included in the review and 40 studies (21,868 participants) were included in the meta-analysis. The participants’ mean age was 73.1 ± 7.1 years, and 66.3% (15,054 participants) were women. Studies were mostly conducted in Europe (n = 15), North America (n = 13), and Oceania (n = 10). Multicomponent training involving multiple exercises (eg, aerobic, strength and balance; 29 RCTs) was the most common intervention modality, followed by aerobic (8 RCTs) and strength (5 RCTs) training. Exercise interventions had a mean frequency of 3 times/week, with each session lasting approximately 50 minutes, and were administered at a moderate intensity. The average compliance rate with exercise training was 65%. Comparator groups were often active controls that ranged from attention controls to more intensive interventions.
Main outcome measures. The 6 binary outcomes investigated were fallers who fell at least once, multiple times, or at least twice; fractures; hospitalization; and mortality. Estimates of outcomes were combined using risk ratios (RRs) using DerSimonian and Laird’s random-effects model (Mantel-Haenszel method). Heterogeneity was evaluated using I2 statistics, and trials with low rates of compliance (< 30%) with exercise intervention or high attrition (> 40%) were excluded in primary analyses.
Main results. Exercise training significantly reduced the risk of falls by 12% (n = 20 RCTs; 4420 participants; RR, 0.88; 95% confidence interval [CI], 0.79-0.98) and injurious falls by 26% (9 RCTs; 4481 participants; RR, 0.74; 95% CI, 0.62-0.88), and reduced the risk of fractures by 16% (19 RCTs; 8410 participants; RR, 0.84; 95% CI, 0.71-1.00; P = 0.05). Exercise training did not decrease the risk of multiple falls (13 RCTs; 3060 participants; RR, 0.86; 95% CI, 0.68-1.08), hospitalization (12 RCTs; 5639 participants; RR 0.94; 95% CI, 0.80-1.12), or mortality (29 RCTs; 11,441 participants; RR 0.96; 95% CI, 0.85-1.09). Sensitivity analyses yielded similar results, with the exception of the fixed-effect meta-analysis for the risk of fracture that showed a significant effect of long-term exercise training (RR, 0.84; 95% CI, 0.70-1.00; P = 0.047). Meta-regression analysis on mortality and falls suggested that exercise frequency between 2 and 3 times per week was optimal and beneficial.
Conclusion. Long-term exercise training of 1 year or longer in duration is associated with a reduction in falls, injurious falls, and fractures in older adults. Moreover, moderate intensity, multicomponent exercise training performed 2 to 3 times weekly is likely safe and effective in this vulnerable population.
Commentary
Falls are exceedingly common (1 in 3 older Americans fall each year) and are the leading cause of fatal and nonfatal injuries in persons over the age of 65 years.1,2 While fall prevention is a public health priority and a topic of interest in many research studies, there are important gaps in knowledge regarding optimal strategies to prevent falls and fall-related injuries in this high-risk population. The study reported by de Souto Barreto and colleagues provides new insights to address several of these gaps and may have a significant impact on the clinical practice of fall prevention in geriatric medicine.
Studies show that a single exercise intervention of short- to medium-term duration can prevent falls in community-dwelling older adults.3 However, the effects of long-term exercise training (ie, intervention lasting longer than a year) on fall prevention in this population is less well characterized. This study is the first meta-analysis that aimed to evaluate the potential beneficial impact of long-term exercise training on falls and adverse fall-related outcomes in adults ≥ 60 years of age who are prone to falls. The study’s findings indicate that long-term exercise training reduces the risk of falling by 12%, injurious falls by 26%, and factures by 16%. These results are important in that they add compelling evidence that exercise training of any duration can reduce falls and some fall-related adverse outcomes. Furthermore, the positive effects of long-term exercise training appear to mitigate some of the fatal and nonfatal injuries attributable to falls—the leading cause of such injuries in older adults.
The modality (type) and dose (frequency) of exercise training are important components of “exercise prescription” for older adults. However, there is a lack of research evidence to help clearly define these exercise parameters to better guide development of consensus exercise recommendations for older patients. This gap in knowledge limits the clinicians’ ability to recommend evidence-based treatment regimens to older adults who are at higher risk for falls. Moreover, although exercise programs are rarely associated with serious adverse events, recent findings from the Lifestyle Interventions and Independence for Elders (LIFE) study found a modest and nonstatistically significant association between long-term, moderate-intensity physical activity programs and an increase in hospitalizations and mortality in older adults.4,5 Taken together, these gaps in knowledge highlight the urgent need to better understand the optimal methods for administering exercise programs in older adults as well as the need for critical appraisals of the benefits and harms associated with long-term exercise training in this vulnerable population.
The results reported by de Souto Barreto and colleagues helped to address these questions. In this study, the authors found that long-term multicomponent training, particularly moderate intensity with balance exercises performed 2 to 3 times a week, appears to be a safe and effective intervention for reducing falls and injurious falls in older adults. Importantly, this type of long-term exercise regimen does not increase hospitalization and mortality, and thus supports the notion that exercise therapy is safe in older adults. Therefore, information gained from this meta-analysis should help to guide clinicians to devise a patient-centered exercise prescription for fall prevention.
The current study was well designed and has a number of strengths. The design of the systematic review and meta-analysis allowed aggregation of data from multiple trials, resulting in a more robust point estimate to evaluate the effects of long-term exercise training on falls and fall-related outcomes that otherwise cannot be achieved with individual trials. In addition, the emphasis on long-term exercise training in older adults in the setting of falls and adverse fall-related outcomes addresses a key area of research that currently lacks a sufficient evidence base. There are also several limitations in this study, primarily due to the nature of its meta-analysis design. For instance, the study populations included in the analysis are highly heterogeneous and range from those with dementia to healthy participants. In addition, long-term exercise training, defined as a duration ≥ 1 year, was arbitrarily established as the minimum period of intervention. Thus, potential important studies that include interventions of significant duration, but less than 1 year, may not have been captured in this analysis.
Applications for Clinical Practice
Falls in older adults are common and may lead to devastating health consequences. The implementation of a long-term, multicomponent, moderate-intensity exercise regimen performed 2 to 3 times weekly can reduce falls and injurious falls in older adults.
—Fred Ko, MD, MS
1. Schiller JS, Kramarow EA, Dey AN. Fall injury episodes among noninstitutionalized older adults: United States, 2001-2003. Adv Data. 2007(392);1-16.
2. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50:116-119.
3. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51:1750-1758.
4. Liu CJ, Latham, NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev. 2009;CD002759.
5. Pahor M, Guralnik JM, Ambrosius WT, et al. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial. JAMA. 2014;311:2387-2396.
1. Schiller JS, Kramarow EA, Dey AN. Fall injury episodes among noninstitutionalized older adults: United States, 2001-2003. Adv Data. 2007(392);1-16.
2. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50:116-119.
3. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51:1750-1758.
4. Liu CJ, Latham, NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev. 2009;CD002759.
5. Pahor M, Guralnik JM, Ambrosius WT, et al. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial. JAMA. 2014;311:2387-2396.