Exercise and Falls Prevention Preliminary Results from a Community-Based Exercise Intervention

1. Exercise and Falls PreventionPreliminary Results from a Community-Based Exercise Intervention April 3, 2009 Christian Thompson, Ph.D. Department of Exercise & Sport Science University of San Francisco

2. The Older Adult Continuum

3. This Can Happen to Both of Them!

4. Too Bad It’s Not Funny… • Over 1/3 of people aged of 65+ fall each year • In 2004, over 1.8 million seniors were treated for fall-related injuries at emergency rooms • Approx. 400,000 fractures per year due to falls • Over 20% of hip fractures result in death in 1 yr • Problem will only continue to increase with changing demographics Sources: CDC, 2007; Kannus et al., 2005; Ngyuen et al., 2007

5. Relevant Health Data for California and San Francisco County • Over 25% of people living in San Francisco are over the age of 65 • Almost 12% of older Californians fell more than once in 2003 • Diagnosed diabetes increased from 15% in 2001 to 17.5% in 2005 • Diagnosed hypertension increased from 53% in 2001 to 60% in 2003 Source: UCLA Center for Health Policy Research, 2008

6. Extrinsic Factors External Issues Weather or outdoor conditions House clutter and obstacles Poor lighting Lack of adaptive devices in the home Inappropriate footwear/clothing Intrinsic Factors Internal Issues History of Falling Chronic Diseases & Medical Conditions Sensory/Vestibular Impairments Medication Effects Functional Level (Strength, Posture, Gait) Factors Affecting Falls Risk with number of risk factors present Sources: (Rose, 2003; Tinetti et al., 1988; Carter, 2001; Lehtola et al., 2006)

7. Multifactorial Address both I&E risks Environmental hazards Medication modification Sensory deficits Disease management Exercise Education Exercise-Only Address modifiable functional limitations Lower body strength Static/Dynamic balance Flexibility Gait modification Cardiovascular Group vs. Individual Supervised vs. Unsupervised Regularly ImplementedIntervention Strategies Sources: Lord et al., 1995; Province et al., 1995; Tinetti et al., 1994

8. Intervention Characteristics Exercise (6) Home Hazard Reduction (3) Day et al., 2002, Sjosten et al., 2007; Steinberg et al., 2000) Medical/Medication Intervention (5) Day et al., 2002; Steinberg et al., 2000; Shumway-Cook et al., 2007; Campbell et al., 1999; Sjosten et al., 2007 Vision (2) Day et al., 2002; Shumway-Cook et al., 2007 Education (2) Shumway-Cook et al., 2007; Sjosten et al., 2007 Nutrition (1) Swanenburg et al., 2007 Randomized Controlled TrialsMultifactorial Interventions – 6 Studies

9. Relevant Findings Falls Reduction Significant reduction in falls in 3 of 6 studies Day et al., 2002; Steinberg et al., 2000; Swanenburg et al., 2007 Fall Risk Reduction Improvement in some/all fall risk factors in 5 of 6 studies Measured by Balance assessment inventories, Strength, Gait Analysis, Agility/Dynamic Balance Assessments, Balance Confidence/Fear of Falling scales Only Sjosten, et al., 2007 did not report improvement Limitations Variability in participant selection, exercise dose, exercise program content, program duration Questionable statistical analyses Randomized Controlled TrialsMultifactorial Interventions

10. Included Exercise Program Characteristics Resistance Training (7) – Barnett et al., 2003; Freiberger et al., 2007; Woo et al., 2007; Suzuki et al., 2004; Luukinen et al., 2007; Rubenstein et al., 2000; Lin et al., 2006 Static Balance Training (5) – Barnett et al., 2003; Freiberger et al., 2007; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000 Agility/Dynamic Balance Training (8) Gait Enhancement Training (4) – Barnett et al., 2003; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000 Aerobic/Cardiovascular Training (4) – Barnett et al., 2003; Freiberger et al., 2007; Luukinen et al., 2007; Rubenstein et al., 2000 Flexibility Training (6) – All except Madureira 2007 & Suzuki 2004 Tai Chi (4) – Barnett et al., 2003; Woo et al., 2007; Li et al., 2005, Lin et al., 2006 Supervised Group Exercise (4), Home-based Exercise (1), Combination (4) Randomized Controlled TrialsExercise-Only Interventions – 9 Studies

11. Relevant Findings Falls Reduction Significant reduction in falls in 6 of 9 studies Barnett et al., 2003; Freiberger et al., 2007; Li et al., 2005; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000 Fall Risk Reduction Improvement in some/all fall risk factors in 5 of 6 studies Measured by Balance assessment inventories, Strength, Gait Analysis, Agility/Dynamic Balance Assessments, Balance Confidence/Fear of Falling scales Only Woo, et al., 2007 did not report improvement Limitations Variability in participant selection, exercise dose, exercise program content, program duration Questionable statistical analyses Randomized Controlled Trials Exercise-Only Interventions

12. Conclusions Concerning Exercise for Falls Prevention • Exercise has been shown to exert a strong effect on functional level and modifiable intrinsic falls risk factors • Exercise has been shown in several studies to reduce future falls • Dose-response studies are needed to determine optimal training recommendations

13. Purpose & Hypotheses Determine the effect of a 12-week progressive functional training program on falls risk, balance confidence, perceptions of health and falls occurrence in community-dwelling older adults who have sustained at least one accidental fall in the past 6 months

14. Intervention Description 12-week Progressive Program Three 4-week phases • Dynamic warm-up • Sensory integration exercises • Strength training • Balance training • Gait enhancement training • Dynamic cool-down 60 Minutes, 2 days per week Led by certified fitness professionals

15. Exercise Progression Examples

16. Outcome Measures • Physiological Assessments • Functional Reach Test (Limits of Stability) • 30 sec Chair Stand (Lower Body Strength) • Timed Up-And-Go (Agility & Dyn. Balance) • Questionnaires • Activity Specific Balance Confidence Scale • SF-12 Quality of Life Questionnaire • Falls Occurrence • Monthly Phone Interviews for 1 year

17. Study Sample • Community-dwelling older adults ≥ 65 yrs • Sustained accidental fall in last 6 mos • FICSIT falls definition • Must be able to ambulate 30 feet w/o AD • Free of significant sensory/vestibular dysfunction, PD, uncontrolled metabolic disease, uncontrolled cardiovascular disease • Available for study duration

18. Recruitment & Intervention Total Phone Contacts 82 Attended Screening 61 Did Not Qualify/Not Interested 21 Did Not Qualify 10 Qualified and Did Not Enroll 6 Completed 20+ Visits 35 Qualified and Enrolled 45 Controls 40 Dropped Out 3 Completed < 20 Visits 7

19. Physiological MeasuresANCOVA – Baseline as Covariate p = .0001 % Change p = .008 p = .04

20. Acknowledgements Funding: San Francisco Dept. Aging & Adult Services California Wellness Foundation University of San Francisco Faculty Development Fund Community Partners: 30th Street Senior Center, San Francisco Senior Centers, Inc., Kaiser San Francisco, San Francisco Examiner, Fromm Institute for Lifelong Learning at USF Research Associates/Assistants: Dr. Diana Lattimore, Irina Fedulow, Brigitte Dubon, Sarah Simunovich, Jermelle Newman, Taylor Harrington, Sarah Wallenrod, Patricia Bufalini, Matt Lieb, Ben Dessard

21. Dr. Christian Thompson Department of Exercise & Sport Science University of San Francisco 2130 Fulton Street San Francisco, CA 94117 cjthompson@usfca.edu (415) 422-5270