At age 75, Betsy believed that people need to stay active and involved throughout life. She remained physically active mostly by playing golf, though she used a golf cart. Then she began to fall--four times over the past few years. She attributed these tumbles to her own carelessness and to being in too much of a hurry.
When she attended a screening program for fall risk factors at her senior center, Betsy was taken aback when told she needed to be even more physically active then she was. A specific exercise program that involved walking, weight lifting and balance exercises was recommended. Gradually during the first three to four months of the program, Betsy found she gained a little more energy each day, had less trouble falling asleep, felt stronger and could steadily increase the amount of weight she used for her exercises. Balance drills that she found difficult at first were increasingly easy. She had more self-confidence and went for two years without a fall.
CURRENT RESEARCH
The current approach to fall prevention in community settings is based on addressing multiple risk factors. With this method, each person's specific deficits determine what is done to prevent falls. For example, based on a screening test of muscle strength, physically weak adults are prescribed strength training. Also, a review of medications might result in some drugs such as sedatives being stopped, decreased or replaced--by nonsedating alternatives, for example.
Multiple risk factors aside, though, new evidence is being discovered about the effects of exercise alone on falls. A growing body of scientific evidence suggests regular exercise reduces the risk of falling in older adults. One major research project called "Frailty and Injuries: Cooperative Studies of Intervention Techniques" (ficsit) examined seven distinct aspects of exercise. Findings indicated an overall reduced risk of falls of about 10% following exercise intervention programs.
Some exercise studies, however, show no effect of exercise on fall risk while others reveal reductions in fall risk of as much as 40% to 50%. While experts believe the type of exercise program used is crucial, it is not yet clear exactly what types of physical activities are best for preventing falls. The ficsit analysis asked whether balance training, strength training or endurance (aerobic) training had the largest effect on fall risk. It found that balance training, such as tai chi, had the largest beneficial effect. ficsit was funded by the National Institute on Aging and the National Institute of Nursing Research, both in Bethesda, Md. The principal investigator was Mary Tinetti of Yale.
Other research has found that exercise appears to be particularly beneficial for people who fall the most. A home exercise program conducted in New Zealand, with which I was involved, reduced risk of falls in older women by around 40%. The study, headed by John Campbell, professor of geriatric medicine at the Dunedin School of Medicine, Dunedin, New Zealand, and reported in the British Medical Journal (Oct. 25, 1997) showed that the greatest improvement occurred in the group that had experienced the most falls in the year prior to the exercise program.
Preventing falls is only one reason for older adults to get regular exercise. Physical activity also reduces the risk of conditions such as heart disease, high blood pressure, osteoporosis, diabetes and depression. Exercise sustains the ability of older adults to remain independent and do activities of daily life. Physically active adults live longer.
FOUR TYPES
Although the ficsit analysis suggested balance training is beneficial, strength training, such as leg lifts or use of weights, also improves health in older adults. People lose muscle mass and strength with age, which makes it more difficult to do tasks of everyday life. Strength training is safe and effective, even for frail adults living in nursing homes.
Walking and other endurance activities, such as swimming or aerobic dance, also offer numerous health benefits. Recent studies confirm the remarkable advantages of a brisk walk of about 30 minutes each day. For example, a study published in the New England Journal of Medicine (Aug. 26, 1999) compared the effects of walking with those of vigorous exercise in preventing coronary heart disease in women. Lead researcher JoAnn E. Manson, codirector of women's health at Brigham and Women's Hospital, Boston, and an associate professor at Harvard Medical School, found that walking reduces the risk of heart attacks and related deaths by up to 50% in older women and mitigates the effects of a risk factor like poor balance in precipitating falls.
Flexibility training also is recommended for elders. Athletes and younger people are often told that stretching helps them warm up, cool down and probably prevent exercise injuries; this also needs to be stressed among older individuals.
A community program should offer a menu of enjoyable forms and combinations of the four types of exercises (endurance, strength, balance and flexibility) and help older people select appropriate options. Ideally older adults would exercise mainly on their own at home or work, under the supervision of an exercise leader.
According to the 1996 surgeon general's report fewer than one in five older Americans is sufficiently active--defined as doing 30 minutes a day of moderate intensity activity such as brisk walking. In terms of exercise, the largest group of older adults are those who do some moderate activity but less than 30 minutes a day. Such elders should be encouraged to do just a little more and gradually work up to a half-hour per day.
A free National Institute on Aging (NIA) publication describes in detail a sample exercise program for older adults. Copies of "Exercise: A Guide From the National Institute on Aging" can be requested by contacting the NIA at (800) 222-2225 or niainfo@lkacc.com.
David M. Buchner is chief of the Physical Activity and Health Branch, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga.
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