Exercise to prevent falls in older adults: an updated systematic review and meta-analysis

Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, Cumming RG, Herbert RD, Close JC, Lord SR
Br J Sports Med. 2016 Oct 4. pii: bjsports-2016-096547. doi: 10.1136/bjsports-2016-096547

OBJECTIVE:

Previous meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether characteristics of the trial design, sample or intervention are associated with greater fall prevention effects.

DESIGN:

Update of a systematic review with random effects meta-analysis and meta-regression.

DATA SOURCES:

Cochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016.

STUDY ELIGIBILITY CRITERIA:

We included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group.

RESULTS:

99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, p<0.001, I² 47%, 69 comparisons) with greater effects seen from exercise programmes that challenged balance and involved more than 3 hours/week of exercise. These variables explained 76% of the between-trial heterogeneity and in combination led to a 39% reduction in falls (incident rate ratio 0.61, 95% CI 0.53 to 0.72, p<0.001). Exercise also had a fall prevention effect in community-dwelling people with Parkinson’s disease (pooled rate ratio 0.47, 95% CI 0.30 to 0.73, p=0.001, I² 65%, 6 comparisons) or cognitive impairment (pooled rate ratio 0.55, 95% CI 0.37 to 0.83, p=0.004, I² 21%, 3 comparisons). There was no evidence of a fall prevention effect of exercise in residential care settings or among stroke survivors or people recently discharged from hospital.

SUMMARY/CONCLUSIONS:

Exercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinson’s disease and cognitive impairment.

Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial

Mirelman A, Rochester L, Maidan I, Del Din S, Alcock L, Nieuwhof F, Rikkert MO, Bloem BR, Pelosin E, Avanzino L, Abbruzzese G, Dockx K, Bekkers E, Giladi N, Nieuwboer A, Hausdorff JM
Lancet. 2016 Sep 17;388(10050):1170-82

BACKGROUND:

Age-associated motor and cognitive deficits increase the risk of falls, a major cause of morbidity and mortality. Because of the significant ramifications of falls, many interventions have been proposed, but few have aimed to prevent falls via an integrated approach targeting both motor and cognitive function. We aimed to test the hypothesis that an intervention combining treadmill training with non-immersive virtual reality (VR) to target both cognitive aspects of safe ambulation and mobility would lead to fewer falls than would treadmill training alone.

METHODS:

We carried out this randomised controlled trial at five clinical centres across five countries (Belgium, Israel, Italy, the Netherlands, and the UK). Adults aged 60-90 years with a high risk of falls based on a history of two or more falls in the 6 months before the study and with varied motor and cognitive deficits were randomly assigned by use of computer-based allocation to receive 6 weeks of either treadmill training plus VR or treadmill training alone. Randomisation was stratified by subgroups of patients (those with a history of idiopathic falls, those with mild cognitive impairment, and those with Parkinson’s disease) and sex, with stratification per clinical site. Group allocation was done by a third party not involved in onsite study procedures. Both groups aimed to train three times per week for 6 weeks, with each session lasting about 45 min and structured training progression individualised to the participant’s level of performance. The VR system consisted of a motion-capture camera and a computer-generated simulation projected on to a large screen, which was specifically designed to reduce fall risk in older adults by including real-life challenges such as obstacles, multiple pathways, and distracters that required continual adjustment of steps. The primary outcome was the incident rate of falls during the 6 months after the end of training, which was assessed in a modified intention-to-treat population. Safety was assessed in all patients who were assigned a treatment. This study is registered with ClinicalTrials.gov, NCT01732653.

FINDINGS:

Between Jan 6, 2013, and April 3, 2015, 302 adults were randomly assigned to either the treadmill training plus VR group (n=154) or treadmill training alone group (n=148). Data from 282 (93%) participants were included in the prespecified, modified intention-to-treat analysis. Before training, the incident rate of falls was similar in both groups (10·7 [SD 35·6] falls per 6 months for treadmill training alone vs 11·9 [39·5] falls per 6 months for treadmill training plus VR). In the 6 months after training, the incident rate was significantly lower in the treadmill training plus VR group than it had been before training (6·00 [95% CI 4·36-8·25] falls per 6 months; p<0·0001 vs before training), whereas the incident rate did not decrease significantly in the treadmill training alone group (8·27 [5·55-12·31] falls per 6 months; p=0·49). 6 months after the end of training, the incident rate of falls was also significantly lower in the treadmill training plus VR group than in the treadmill training group (incident rate ratio 0·58, 95% CI 0·36-0·96; p=0·033). No serious training-related adverse events occurred.

INTERPRETATION:

In a diverse group of older adults at high risk for falls, treadmill training plus VR led to reduced fall rates compared with treadmill training alone.

Risk factors, incidence, consequences and prevention strategies for falls and fall-injury within older indigenous populations: a systematic review

Lukaszyk C, Harvey L, Sherrington C, Keay L, Tiedemann A, Coombes J, Clemson L, Ivers R
Aust N Z J Public Health. 2016 Oct 23

OBJECTIVE:

To examine the risk factors, incidence, consequences and existing prevention strategies for falls and fall-related injury in older indigenous people.

METHODS:

Relevant literature was identified through searching 14 electronic databases, a range of institutional websites, online search engines and government databases, using search terms pertaining to indigenous status, injury and ageing.

RESULTS:

Thirteen studies from Australia, the United States, Central America and Canada were identified. Few studies reported on fall rates but two reported that around 30% of indigenous people aged 45 years and above experienced at least one fall during the past year. The most common hospitalised fall injuries among older indigenous people were hip fracture and head injury. Risk factors significantly associated with falls within indigenous populations included poor mobility, a history of stroke, epilepsy, head injury, poor hearing and urinary incontinence. No formally evaluated, indigenous-specific fall prevention interventions were identified.

CONCLUSION:

Falls are a significant and growing health issue for older indigenous people worldwide that can lead to severe health consequences and even death. No fully-evaluated, indigenous-specific fall prevention programs were identified. Implications for Public Health: Research into fall patterns and fall-related injury among indigenous people is necessary for the development of appropriate fall prevention interventions.

Effects of Tai Chi on Cognition and Fall Risk in Older Adults with Mild Cognitive Impairment: A Randomized Controlled Trial

Sungkarat S, Boripuntakul S, Chattipakorn N, Watcharasaksilp K, Lord SR
J Am Geriatr Soc. 2016 Nov 22

OBJECTIVES:

To examine whether combined center- and home-based Tai Chi training can improve cognitive ability and reduce physiological fall risk in older adults with amnestic mild cognitive impairment (a-MCI).

DESIGN:

Randomized controlled trial.

SETTING:

Chiang Mai, Thailand.

PARTICIPANTS:

Adults aged 60 and older who met Petersen’s criteria for multiple-domain a-MCI (N = 66).

INTERVENTION:

Three weeks center-based and 12 weeks home-based Tai Chi (50 minutes per session, 3 times per week).

MEASUREMENTS:

Cognitive tests, including Logical Memory (LM) delayed recall, Block Design, Digit Span forward and backward, and Trail-Making Test Part B-A (TMT B-A), and fall risk index using the Physiological Profile Assessment (PPA).

RESULTS:

At the end of the trial, performance on LM, Block Design, and TMT B-A were significantly better for the Tai Chi group than the control group after adjusting for baseline test performance. The Tai Chi group also had significantly better composite PPA score and PPA parameter scores: knee extension strength, reaction time, postural sway, and lower limb proprioception.

CONCLUSION:

Combined center- and home-based Tai Chi training three times per week for 15 weeks significantly improved cognitive function and moderately reduced physiological fall risk in older adults with multiple-domain a-MCI. Tai Chi may be particularly beneficial to older adults with this condition.

Social Dancing and Incidence of Falls in Older Adults: A Cluster Randomised Controlled Trial

Merom D, Mathieu E, Cerin E, Morton RL, Simpson JM, Rissel C, Anstey KJ, Sherrington C, Lord SR, Cumming RG
PLoS Med. 2016 Aug 30;13(8)

BACKGROUND:

The prevention of falls among older people is a major public health challenge. Exercises that challenge balance are recognized as an efficacious fall prevention strategy. Given that small-scale trials have indicated that diverse dance styles can improve balance and gait of older adults, two of the strongest risk factors for falls in older people, this study aimed to determine whether social dance is effective in i) reducing the number of falls and ii) improving physical and cognitive fall-related risk factors.

METHODS AND FINDINGS:

A parallel two-arm cluster randomized controlled trial was undertaken in 23 self-care retirement villages (clusters) around Sydney, Australia. Eligible villages had to have an appropriate hall for dancing, house at least 60 residents, and not be currently offering dance as a village activity. Retirement villages were randomised using a computer generated randomisation method, constrained using minimisation. Eligible participants had to be a resident of the village, be able to walk at least 50 m, and agree to undergo physical and cognitive testing without cognitive impairment. Residents of intervention villages (12 clusters) were offered twice weekly one-hour social dancing classes (folk or ballroom dancing) over 12 mo (80 h in total). Programs were standardized across villages and were delivered by eight dance teachers. Participants in the control villages (11 clusters) were advised to continue with their regular activities.

MAIN OUTCOMES:

falls during the 12 mo trial and Trail Making Tests.

SECONDARY OUTCOMES:

The Physiological Performance Assessment (i.e., postural sway, proprioception, reaction time, leg strength) and the Short Physical Performance Battery; health-related physical and mental quality of life from the Short-Form 12 (SF-12) Survey. Data on falls were obtained from 522 of 530 (98%) randomised participants (mean age 78 y, 85% women) and 424 (80%) attended the 12-mo reassessment, which was lower among folk dance participants (71%) than ballroom dancing (82%) or control participants (82%, p = 0.04). Mean attendance at dance classes was 51%. During the period, 444 falls were recorded; there was no significant difference in fall rates between the control group (0.80 per person-year) and the dance group (1.03 per person-year). Using negative binomial regression with robust standard errors the adjusted Incidence Rate Ratio (IRR) was 1.19 (95% CI: 95% CI = 0.83, 1.71). In exploratory post hoc subgroup analysis, the rate of falls was higher among dance participants with a history of multiple falls (IRR = 2.02, 95% CI: 1.15, 3.54, p = 0.23 for interaction) and with the folk dance intervention (IRR = 1.68, 95% CI: 1.03, 2.73). There were no significant between-group differences in executive function test (TMT-B = 2.8 s, 95% CI: -6.2, 11.8). Intention to treat (ITT) analysis revealed no between-group differences at 12-mo follow-up in the secondary outcome measures, with the exception of postural sway, favouring the control group. Exploratory post hoc analysis by study completers and style indicated that ballroom dancing participants apparently improved their gait speed by 0.07 m/s relative to control participants (95% CI: 0.00, 0.14, p = 0.05). Study limitations included allocation to style based on logistical considerations rather than at random; insufficient power to detect differential impacts of different dance styles and smaller overall effects; variation of measurement conditions across villages; and no assessment of more complex balance tasks, which may be more sensitive to changes brought about by dancing.

CONCLUSIONS:

Social dancing did not prevent falls or their associated risk factors among these retirement villages’ residents. Modified dance programmes that contain “training elements” to better approximate structured exercise programs, targeted at low and high-risk participants, warrant investigation.

The impact of geographical location on trends in hospitalisation rates and outcomes for fall-related injuries in older people

Sukumar DW, Harvey LA, Mitchell RJ, Close JC
Aust N Z J Public Health. 2016 Aug;40(4):342-8

OBJECTIVE:

This population-based study investigates the influence of geographical location on hospital admissions, utilisation and outcomes for fall-related injury in older adults, adjusting for age, sex and comorbidities.

METHODS:

A linked dataset of all admissions of NSW residents aged 65 and older, hospitalised at least once for a fall-related injury between 2003 and 2012, was used to estimate rates of hospitalisations, total lengths-of-stay, 28-day readmissions, and 30-day mortalities. These were standardised for age, sex, comorbidity, and remoteness.

RESULTS:

Compared to urban residents, rural residents were hospitalised less (p<0.0001) and hospitalisation rates increased at a lower rate (0.8% vs 2.6% per year) from 2003 to 2012. Rural residents had a shorter median total length of stay (5 vs 7 days, p<0.0001), a higher 28-day readmission rate (18.9% vs 17.0%, p<0.0001) and higher 30-day mortality (5.0% vs 4.9%, p=0.0046).

CONCLUSIONS:

Over the study period, rural residents of NSW had lower rates of fall-related injury hospitalisation and a lower annual increase in hospitalisation rates compared to urban residents. When hospitalised, rural residents had a shorter length-of-stay, but higher rates of readmission and mortality. These differences existed following standardisation.

IMPLICATIONS:

This study highlights the need for further research to characterise and explain this variability.

The FARSEEING real-world fall repository: a large-scale collaborative database to collect and share sensor signals from real-world falls

Klenk J, Schwickert L, Palmerini L, Mellone S, Bourke A, Ihlen EA, Kerse N, Hauer K, Pijnappels M, Synofzik M, Srulijes K, Maetzler W, Helbostad JL, Zijlstra W, Aminian K, Todd C, Chiari L, Becker C; FARSEEING Consortium
Eur Rev Aging Phys Act. 2016 Oct 30;13:8

BACKGROUND:

Real-world fall events objectively measured by body-worn sensors can improve the understanding of fall events in older people. However, these events are rare and hence challenging to capture. Therefore, the FARSEEING (FAll Repository for the design of Smart and sElf-adaptive Environments prolonging Independent livinG) consortium and associated partners started to build up a meta-database of real-world falls.

RESULTS:

Between January 2012 and December 2015 more than 300 real-world fall events have been recorded. This is currently the largest collection of real-world fall data recorded with inertial sensors. A signal processing and fall verification procedure has been developed and applied to the data. Since the end of 2015, 208 verified real-world fall events are available for analyses. The fall events have been recorded within several studies, with different methods, and in different populations. All sensor signals include at least accelerometer measurements and 58 % additionally include gyroscope and magnetometer measurements. The collection of data is ongoing and open to further partners contributing with fall signals. The FARSEEING consortium also aims to share the collected real-world falls data with other researchers on request.

CONCLUSIONS:

The FARSEEING meta-database will help to improve the understanding of falls and enable new approaches in fall risk assessment, fall prevention, and fall detection in both aging and disease.

Daily-Life Gait Quality as Predictor of Falls in Older People: A 1-Year Prospective Cohort Study

van Schooten KS, Pijnappels M, Rispens SM, Elders PJ, Lips P, Daffertshofer A, Beek PJ, van Dieën JH
PLoS One. 2016 Jul 7;11(7)

Falls can have devastating consequences for older people. We determined the relationship between the likelihood of fall incidents and daily-life behavior. We used wearable sensors to assess habitual physical activity and daily-life gait quality (in terms of e.g. stability, variability, smoothness and symmetry), and determined their predictive ability for time-to-first-and-second-falls. 319 older people wore a trunk accelerometer (Dynaport MoveMonitor, McRoberts) during one week. Participants further completed questionnaires and performed grip strength and trail making tests to identify risk factors for falls. Their prospective fall incidence was followed up for six to twelve months. We determined interrelations between commonly used gait characteristics to gain insight in their interpretation and determined their association with time-to-falls. For all data -including questionnaires and tests- we determined the corresponding principal components and studied their predictive ability for falls. We showed that gait characteristics of walking speed, stride length, stride frequency, intensity, variability, smoothness, symmetry and complexity were often moderately to highly correlated (r > 0.4). We further showed that these characteristics were predictive of falls. Principal components dominated by history of falls, alcohol consumption, gait quality and muscle strength proved predictive for time-to-fall. The cross-validated prediction models had adequate to high accuracy (time dependent AUC of 0.66-0.72 for time-to-first-fall and 0.69-0.76 for -second-fall). Daily-life gait quality obtained from a single accelerometer on the trunk is predictive for falls. These findings confirm that ambulant measurements of daily behavior contribute substantially to the identification of elderly at (high) risk of falling.

Medication use, falls, and fall-related worry in older adults in the United States
Watanabe JH.
Consult. Pharm. 2016; 31(7): 385-393.

Abstract
OBJECTIVE: To compare the prevalence of falls and fall-related concerns of medication users versus nonusers in U.S. seniors. DESIGN: Cross-sectional study.
SETTING: The National Health and Aging Trends Study.
PARTICIPANTS: U.S. nationally representative sample of Medicare beneficiaries in 2011.
OUTCOMES: Comparing subjects who used medications with subjects who did not in the past month, the outcomes were percentages of subjects who experienced 1) a fall in the past month, 2) worry about falling in the past month, 3) being limited by this worry in the past month, 4) a fall in the past year. RESULTS: A greater percentage of medication users experienced falls and fall-related outcomes, compared with non-medication users. Among medication users, 10.29% had a past month fall, compared with 5.42% of non-medication users; 27.69% of medication users worried in the past month about falling, compared with 9.15% of non-medication users; 40.96% of medication users were limited by this worry, compared with 21.21%; 22.82% of medication users had a fall in the past year, compared with 13.15% of non-medication users. CONCLUSION: Seniors who use medications are more likely to fall and to be concerned about falling. Pharmacist involvement in fall prevention continues to be essential.

Quality of standing balance in community-dwelling elderly: age-related differences in single and dual task conditions
Coelho T, Fernandes Â, Santos R, Paúl C, Fernandes L.
Arch. Gerontol. Geriatr . 2016; 67: 34-39.

Abstract
AIM: To examine the relationship between age and quality of standing balance in single and dual task conditions. METHODS: A cross-sectional study was conducted using a sample of 243 community-dwellers aged ≥65 years. Quality of standing balance was assessed by measuring the center of pressure (COP) sway with a pressure platform. Measurements were performed under single task (orthostatic position) and dual task (orthostatic position while performing a verbal fluency task) conditions. RESULTS: The mean age of the participants was 79.1(±7.3)years and 76.1% were women. Older age was associated with an increased COP sway, mainly in the medial/lateral (ML) direction. Most COP sway parameters were higher under dual task conditions than under single task. After controlling for the effect of the number of words enunciated in dual task conditions, only the differences in COP sway parameters in the ML direction remained significant. There was no significant interaction between age group (65-79; ≥80 years) and condition, which indicates that differences in COP sway caused by performing a secondary task were similar for younger and for older participants. CONCLUSION: Age did not seem to influence significantly the decline in the quality of standing balance triggered by performing a concurrent cognitive task. However, older age was consistently associated with poorer standing balance, both in single and in dual task conditions. Therefore, performing a secondary task may lead older individuals to reach their postural stability limits and, consequently, to fall.

Manual and cognitive dual-tasks contribute to fall-risk differentiation in posturography measures
Sample RB, Jackson K, Kinney AL, Diestelkamp W, Smoot Reinert S, Bigelow KE.
J. Appl. Biomech. 2016; ePub(ePub): ePub.

Abstract
Falls occur in 33% of older adults each year, some leading to moderate to severe injuries. To reduce falls and fall related injuries, it is important to identify individuals with subtle risk factors elevating their likelihood of falling. The objective of this study was to determine how postural sway measures differed between fallers and non-fallers under standard and dual-task conditions. Quiet-standing posturography measures were collected from 150 older adults during standard, cognitive, manual and cognitive+manual tasks, and analyzed through traditional and non-linear analyses. Of the traditional measures, M/L sway range and 95% confidence ellipse sway area showed statistically significant differences in all four test conditions between fallers and non-fallers. Although the manual dual-task showed the most stable balance, effect sizes demonstrated larger differences between fallers and non-fallers. Non-linear analysis revealed M/L sample entropy and M/L α-scaling exponent differentiating between fallers and non-fallers with the cognitive task demonstrating larger differences. Based on the results, it is recommended to: 1) apply M/L sway range and 95% confidence ellipse area, 2) utilize the manual task to differentiate between fallers and non-fallers when using traditional analyses, and 3) utilize the cognitive task and M/L alpha and M/L sample entropy when using non-linear analyses.

Fall-related psychological concerns and anxiety among community-dwelling older adults: systematic review and meta-analysis
Payette MC, Belanger C, Léveillé V, Grenier S.
PLoS One 2016; 11(4)

Abstract
Fear of falling and other fall-related psychological concerns (FRPCs), such as falls-efficacy and balance confidence, are highly prevalent among community-dwelling older adults. Anxiety and FRPCs have frequently, but inconsistently, been found to be associated in the literature. The purpose of this study is to clarify those inconsistencies with a systematic review and meta-analysis and to evaluate if the strength of this relationship varies based on the different FRPC constructs used (e.g., fear of falling, falls-efficacy or balance confidence). A systematic review was conducted through multiple databases (e.g., MEDLINE, PsycINFO) to include all articles published before June 10th 2015 that measured anxiety and FRPCs in community-dwelling older adults. Active researchers in the field were also contacted in an effort to include unpublished studies. The systematic review led to the inclusion of twenty relevant articles (n = 4738). A random-effect meta-analysis revealed that the mean effect size for fear of falling and anxiety is r = 0.32 (95% CI: 0.22-0.40), Z = 6.49, p < 0.001 and the mean effect size for falls-efficacy or balance confidence and anxiety is r = 0.31 (95% CI: 0.23-0.40), Z = 6.72, p < 0.001. A Q-test for heterogeneity revealed that the two effect sizes are not significantly different (Q(19) = 0.13, p = n.s.). This study is the first meta-analysis on the relationship between anxiety and FRPCs among community-dwelling older adults. It demonstrates the importance of considering anxiety when treating older adults with FRPCs.

Fear of falling as a risk factor of mobility disability in older people at five diverse sites of the IMIAS study
Auais M, Alvarado BE, Curcio CL, Garcia A, Ylli A, Deshpande N.
Arch. Gerontol. Geriatr. 2016; 66: 147-153

Abstract
BACKGROUND: Fear of falling (FoF) is a common health problem among older adults. Although the relationship between FoF and limitation in daily activities has been reported, FoF’s relationship to mobility disability, a transitional phase to end-stage disability, is not yet understood. We examined the relationship between FoF and mobility disability among community-dwelling older adults and explored the differences in this relationship among socio-culturally diverse sites. DESIGN: Cross-sectional study.
SETTING: Community.
PARTICIPANTS: 1875 participants (65-74 years) were recruited from five sites and included in the analysis (Kingston, Canada: 394; St-Hyacinthe, Canada: 397; Tirana, Albania: 359; Manizales, Colombia: 341; and Natal, Brazil: 384).
MEASUREMENT: FoF was quantified using the Falls Efficacy Scale-International (FES-I, range: 16-64). Mobility disability was defined as difficulty climbing a flight of stairs or walking 400m without assistance. RESULTS: Overall, 21.5% of participants reported high FoF (FES-I>27). The average FoF scores were significantly different between the sites (p<0.001) and higher in women (p<0.001). In general, 36.2% of participants reported mobility disability. The distribution of mobility disability was significantly different at the five study sites (ranged from 19.8% at Kingston, Canada to 50.7% at Tirana, Albania, p<0.001). After adjusting for covariates, those with high and moderate FoF had about 3 times (95% CI: 2.59-3.83) and 2.5 times (95% CI: 1.99-2.91) higher risk of mobility disability, respectively, compared to those with no/low FoF.
CONCLUSIONS: FoF was significantly associated with risk of mobility disability across the sites. The strength of this relationship appears to be different between the five sites.

Interventions incorporating physical and cognitive elements to reduce falls risk in cognitively impaired older adults
Booth V, Hood V, Kearney F.
JBI Database Syst. Rev Implement. Rep. 2016; 14(5): 110-135

Abstract
BACKGROUND: Cognitive impairment is a risk factor for falls. Older adults with cognitive impairment (such as dementia) have an increased risk of falling compared with age-matched individuals without a cognitive impairment. To reduce falls in this population, interventions could theoretically target and train both physical and cognitive abilities. Combining and addressing cognitive components in falls rehabilitation is a novel and emerging area of healthcare. OBJECTIVES: The objective of this review was to identify the effectiveness of combined cognitive and physical interventions on the risk of falls in cognitively impaired older adults. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Older persons who were 65 years or older and identified as having a cognitive impairment either through diagnosis or assessment of global cognition. TYPES OF INTERVENTION(S): Multifactorial or multiple interventions where physical and cognitive elements were combined was compared against standard care or a single element intervention. TYPES OF STUDIES: Randomized controlled trials (RCTs), controlled clinical trials and experimental studies in which randomization was used. OUTCOMES: Outcomes related to falls, including falls rate, specific falls risk measures (i.e. Physiological Profile Assessment) or related clinical outcome measures (i.e. Timed Up and Go test, Tinetti and gait speed). SEARCH STRATEGY: A three-step search strategy was utilized in this review, including search of electronic databases: CENTRAL, JBISRIR, MEDLINE, EMBASE, AMED, CINAHL and PsychINFO. Initial keywords used were dementia, cognitive impairment, memory loss, exercise, rehabilitation and accidental falls. Grey literature (Google Scholar) and trials registers (Current Controlled Trials) searches were also completed. METHODOLOGICAL QUALITY: The methodological quality of included studies was assessed using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) software. DATA EXTRACTION: Data was extracted from articles included in the review using the standardized data extraction tool from JBI-MAStARI. DATA SYNTHESIS: A quantitative meta-analysis was performed where possible. Otherwise, data synthesis was in the form of narrative review. Sub-group analysis according to level of cognitive impairment was completed where possible. RESULTS: Eight RCTs were included in this review; they evaluated the effectiveness of multicomponent exercise programs, including physical and cognitive activities, music-based group exercise and mind-body tai chi on falls related outcomes. Most of the studies were of good quality with an average quality score of 7.5. Four studies reported effectiveness based on the number of falls, half of which reported a significant difference between the groups, but pooling of results into meta-analysis was not possible because of differences in reporting of the outcome. Falls related outcomes that were combined in meta-analysis included balance (Berg balance scale), functional mobility (Timed Up and Go) and gait speed (m/s). There was a statistically significant improvement in balance and gait speed following the intervention; however, the studies were too heterogeneous to be included in the analysis from the functional mobility results.
CONCLUSION: Overall, multicomponent interventions incorporating both physical and cognitive components demonstrated positive effects on balance, functional mobility and gait speed when compared with a control and had significantly better effect on balance and gait speed within mild cognitive impairment populations.

Antidepressant use and recurrent falls in community-dwelling older adults: findings from the Health ABC Study
Marcum ZA, Perera S, Thorpe JM, Switzer GE, Castle NG, Strotmeyer ES, Simonsick EM, Ayonayon HN, Phillips CL, Rubin S, Zucker-Levin AR, Bauer DC, Shorr RI, Kang Y, Gray SL, Hanlon JT.
Ann. Pharmacother. 2016; ePub(ePub): ePub.

Abstract
BACKGROUND: Few studies have compared the risk of recurrent falls across various antidepressant agents-using detailed dosage and duration data-among community-dwelling older adults, including those who have a history of a fall/fracture. OBJECTIVE: To examine the association of antidepressant use with recurrent falls, including among those with a history of falls/fractures, in community-dwelling elders. METHODS: This was a longitudinal analysis of 2948 participants with data collected via interview at year 1 from the Health, Aging and Body Composition study and followed through year 7 (1997-2004). Any antidepressant medication use was self-reported at years 1, 2, 3, 5, and 6 and further categorized as (1) selective serotonin reuptake inhibitors (SSRIs), (2) tricyclic antidepressants, and (3) others. Dosage and duration were examined. The outcome was recurrent falls (≥2) in the ensuing 12-month period following each medication data collection. RESULTS: Using multivariable generalized estimating equations models, we observed a 48% greater likelihood of recurrent falls in antidepressant users compared with nonusers (adjusted odds ratio [AOR] = 1.48; 95% CI = 1.12-1.96). Increased likelihood was also found among those taking SSRIs (AOR = 1.62; 95% CI = 1.15-2.28), with short duration of use (AOR = 1.47; 95% CI = 1.04-2.00), and taking moderate dosages (AOR = 1.59; 95% CI = 1.15-2.18), all compared with no antidepressant use. Stratified analysis revealed an increased likelihood among users with a baseline history of falls/fractures compared with nonusers (AOR = 1.83; 95% CI = 1.28-2.63). CONCLUSION: Antidepressant use overall, SSRI use, short duration of use, and moderate dosage were associated with recurrent falls. Those with a history of falls/fractures also had an increased likelihood of recurrent falls.

Exercise for reducing fear of falling in older people living in the community: Cochrane systematic review and meta-analysis
Kumar A, Delbaere K, Zijlstra GA, Carpenter H, Iliffe S, Masud T, Skelton D, Morris R, Kendrick D.
Age Ageing 2016; 45(3): 345-352.

Abstract
OBJECTIVE: to determine the effect of exercise interventions on fear of falling in community-living people aged ≥65. DESIGN: systematic review and meta-analysis. Bibliographic databases, trial registers and other sources were searched for randomised or quasi-randomised trials. Data were independently extracted by pairs of reviewers using a standard form. RESULTS: thirty trials (2,878 participants) reported 36 interventions (Tai Chi and yoga (n = 9); balance training (n = 19); strength and resistance training (n = 8)). The risk of bias was low in few trials. Most studies were from high-income countries (Australia = 8, USA = 7). Intervention periods (<12 weeks = 22; 13-26 weeks = 7; >26 weeks = 7) and exercise frequency (1-3 times/week = 32; ≥4 times/week = 4) varied between studies. Fear of falling was measured by single-item questions (7) and scales measuring falls efficacy (14), balance confidence (9) and concern or worry about falling (2). Meta-analyses showed a small to moderate effect of exercise interventions on reducing fear of falling immediately post-intervention (standardised mean difference (SMD) 0.37, 95% CI 0.18, 0.56; 24 studies; low-quality evidence). There was a small, but not statistically significant effect in the longer term (<6 months (SMD 0.17, 95% CI -0.05, 0.38 (four studies) and ≥6 months post-intervention SMD 0.20, 95% CI -0.01, 0.41 (three studies)). CONCLUSIONS: exercise interventions probably reduce fear of falling to a small to moderate degree immediately post-intervention in community-living older people. The high risk of bias in most included trials suggests findings should be interpreted with caution. High-quality trials are needed to strengthen the evidence base in this area.

Factors associated with injurious falls in residential care facilities
Towne SD, Cho J, Smith ML, Ory MG.
J. Aging Health 2016; ePub(ePub): ePub.

Abstract
OBJECTIVE: Despite a growing literature on the epidemiology of falls, little is known about injurious falls in residential care facilities (RCFs). Addressing this gap, this study examined demographic, interpersonal, institutional, and community factors associated with injurious falls in RCFs. METHOD: We conducted analyses using a nationally representative sample (n = 733,309) of RCF residents (2010) examining whether or not a resident experienced a fall that resulted in any injury (past year). RESULTS: Overall, 15% of RCF residents experienced an injurious fall. Residents needing assistance with activities of daily living were more likely to experience injurious falls (adjusted-OR = 1.85), whereas males (adjusted-OR = 0.74) and those residing in smaller facilities (adjusted-OR = 0.68) were less likely. Other resident sociodemographic characteristics, payment status, social connectedness, and rurality were not significant independent predictors. DISCUSSION: Research further exploring multifactorial fall prevention screening and treatment programs in RCFs is recommended for reducing injurious falls in this understudied setting.

Comparison of two different exercise approaches: tai chi versus Otago, in community-dwelling older women
Son NK, Ryu YU, Jeong HW, Jang YH, Kim HD.
J. Geriatr. Phys. Ther. 2016; 39(2): 51-57.

Abstract
BACKGROUND AND PURPOSE: Regular exercise can delay age-related risk factors and can maintain or improve physical health and activity in older adults leading to a decrease in fall risk. The purpose of this study was to compare 2 different interventions for fall prevention, tai chi (TC) and Otago, by examining lower extremity strength, balance, and spatiotemporal gait parameters in community-dwelling older women. METHODS: We performed a randomized trial in which subjects were assigned to 1 of 2 groups: the TC group (n = 21; age, 72.8 ± 4.7 years, range: 65-83 years), which participated in a modified Sun-style TC exercise program; and the Otago group (n = 24; age, 71.5 ± 3.6 years, range: 65-79 years), which participated in the Otago exercise program. The Timed Up and Go (TUG) test, functional reach (FR) test, one-leg standing (OLS) test, 5 times sit-to-stand test (5×STS), 30-second sit-to-stand (30s STS) test, and gait parameters (gait velocity, step length, step width, stride time, and cadence) were measured before and after the intervention. RESULTS: Both groups showed statistically significant improvements in balance (TUG and OLS tests), lower extremity strength (5×STS and 30s STS tests), and spatiotemporal gait parameters, except for step width and step length (P <.05). The Otago group showed a significantly improved FR, whereas the TC group showed a significantly improved step length after the intervention (P <.05). Furthermore, the Otago group exhibited greater improvements in the TUG (P <.001), FR (P <.001), 5×CST (P <.01), and 30-second CST (P <.01) tests: a faster cadence (P <.001) and shorter stride time (P <.001) when compared with the TC group. The TC group showed greater improvements in the OLS test, step length, and step width (P <.01) and faster gait velocity (P <.05) than the Otago group. DISCUSSION AND CONCLUSIONS: The findings from this study support the efficacy of the TC and Otago exercise programs in improving mobility in this sample of subjects. Furthermore, the Otago group showed greater improvement in lower extremity strength, whereas the TC group showed greater improvement in balance (OLS test). Also, the TC group showed a greater improvement in gait velocity after TC training program compared with the Otago exercise program. However, this study does not elucidate which exercise program is a more effective intervention method with older women for fall prevention.

Sedentary behavior and physical activity patterns in older adults after hip fracture: a call to action
Fleig L, McAllister MM, Brasher P, Cook WL, Guy P, Puyat JH, Khan KM, McKay HA, Ashe MC.
J. Aging Phys. Act. 2016; 24(1): 79-84.

Abstract
OBJECTIVES: To characterize patterns of sedentary behavior and physical activity in older adults recovering from hip fracture and to determine characteristics associated with activity. METHODS: Community-dwelling, Canadian adults (65 years+) who sustained hip fracture wore an accelerometer at the waist for seven days and provided information on quality of life, falls self-efficacy, cognitive functioning, and mobility. RESULTS: There were 53 older adults (mean age [SD] 79.5 [7.8] years) enrolled in the study; 49 had valid data and demonstrated high levels of sedentary time (median [p10, p90] 591.3 [482.2, 707.2] minutes/day), low levels of light activity (186.6 [72.6, 293.7]), and MVPA (2 [0.1, 27.6]), as well as few daily steps (2467.7 [617.1, 6820.4]). Regression analyses showed that age, gender, gait speed, and time since fracture were associated with outcomes. CONCLUSIONS: Older adults have long periods of sedentary time with minimal activity. Results are a call to action to encourage people to sit less and move more.

The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise prescription
Bullo V, Bergamin M, Gobbo S, Sieverdes JC, Zaccaria M, Neunhaeuserer D, Ermolao A.
Prev. Med. 2015; 75: 1-11.

Abstract
This systematic review aims to summarize the effects of Pilates exercise training (PET) in elderly population on physical fitness, balance and fall prevention, and its effects on mood states, quality of life and independence in the daily living activities. METHODS: Keyword “Pilates” associated with “elderly”, “aging” and “old subjects” were identified as terms for the literature research in MEDLINE, Embase, PubMed, Scopus, PsycINFO and SPORTDiscus. Only studies published in peer-reviewed journals written in English language were considered. A meta-analysis was performed and effect sizes (ES) calculated. RESULTS: 10 studies were identified (6 RCTs and 4 uncontrolled trials); age ranged from 60 to 80years. Overall, PET showed large ES to improve muscle strength (ES=1.23), walking and gait performances (ES=1.39), activities of daily living, mood states and quality of life (ES=0.94), moderate to high effect on dynamic balance (ES=0.77), small effects on static balance (ES=0.34) and flexibility (ES=0.31), while a small effect on cardio-metabolic outcomes (ES=0.07). CONCLUSIONS: PET should be taken into account as a way to improve quality of life in the elderly, due to the imparted benefits of fall prevention, physical fitness, and mood states. In this context, physicians might include PET as a tool for exercise prescriptions for the elderly.

Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis
SABRINA YOUKHANA, CATHERINE M. DEAN, MOAWOLFF, CATHERINE SHERRINGTON, ANNE TIEDEMANN
Age and Ageing 2016; 0: 1–9

Abstract
Objective: one-third of community-dwelling older adults fall annually. Exercise that challenges balance is proven to prevent falls. We conducted a systematic review with meta-analysis to determine the impact of yoga-based exercise on balance and physical mobility in people aged 60+ years.
Methods: searches for relevant trials were conducted on the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine Database and the Physiotherapy Evidence Database (PEDro) from inception to February 2015. Trials were included if they evaluated the effect of physical yoga (excluding meditation and breathing exercises alone) on balance in people aged 60+ years. We extracted data on balance and the secondary outcome of physical mobility. Standardised mean differences and 95% confidence intervals (CI) were calculated using random-effects models. Methodological quality of trials was assessed using the 10-point Physiotherapy Evidence Database (PEDro) Scale. Results: six trials of relatively high methodological quality, totalling 307 participants, were identified and had data that could be included in a meta-analysis. Overall, yoga interventions had a small effect on balance performance (Hedges’ g = 0.40, 95% CI 0.15–0.65, 6 trials) and a medium effect on physical mobility (Hedges’ g = 0.50, 95% CI 0.06–0.95, 3 trials).
Conclusion: yoga interventions resulted in small improvements in balance and medium improvements in physical mobility in people aged 60+ years. Further research is required to determine whether yoga-related improvements in balance and mobility translate to prevention of falls in older people.

Hearing Loss and Falls: A Systematic Review and Meta-analysis
Nicole Tin-Lok Jiam, BA; Carol Li, MD; Yuri Agrawal, MD, MPH
Laryngoscope 00: Month 2015

Background: Falls are a devastating condition in older individuals. Identifying potentially modifiable risk factors such as hearing loss would provide a substantial public health benefit.
Objective: To evaluate the current evidence for an association between hearing loss and falls risk.
Data Sources: A systematic search of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Scopus, Web of Science, and Cochrane databases was performed in July 2014.
Study Eligibility: Studies were eligible for inclusion if they were published in the peer-reviewed literature. All studies used a predetermined definition of hearing loss. Main outcomes and measurements were fall hospitalization records or selfreports of falls by structured interview or validated questionnaires.
Study Appraisal and Synthesis: Two investigators independently reviewed the literature related to hearing loss, falls, and older adults. We pooled effect sizes from across the studies and performed a meta-analysis to compute an overall effect size.
Results and Limitations: Twelve eligible studies were identified. The odds of falling were 2.39 times greater among older adults with hearing loss than older adults with normal hearing (pooled odds ratio 2.39, 95% confidence interval [CI]: 2.11-2.68). In sensitivity analyses, we restricted the meta-analysis to studies where hearing loss was audiometrically defined (N 5 6) and observed hearing loss to be associated with a 69% increase in the odds of falling (pooled odds ratio 1.69, 95% CI: 1.18-2.19). When we further limited to studies that also performed multivariate regression analyses (N 5 4), the overall effect size did not appreciably change (pooled odds ratio 1.72, 95% CI: 1.07-2.37). We observed a potential positive publication bias in the literature. Limitations of the systematic review and meta-analysis are the cross-sectional designs of most studies and the heterogeneity across studies (Q 5 631, P < .05, I2 5 98.1%).
Conclusions and Relevance: In the published literature, hearing loss is associated with a significantly increased odds of falling in older adults. These findings need to be interpreted in light of the potential for positive publication bias in the literature on this topic.

Updating the Evidence for Physical Activity: Summative Reviews of the Epidemiological Evidence, Prevalence, and Interventions to Promote “Active Aging”
Adrian Bauman, MD, MPH, PhD, Dafna Merom, PhD, Fiona C. Bull, PhD, David M. Buchner, MD, MPH, and Maria A. Fiatarone Singh, MD
Gerontologist, 2016, Vol. 56, No. S2, S268–S280

Abstract
Purpose of the Study: There is a global imperative to increase awareness of the emerging evidence on physical activity (PA) among older adults. “Healthy aging” has traditionally focused on preventing chronic disease, but greater efforts are required to reduce frailty and dependency and to maintain independent physical and cognitive function and mental health and well-being.
Design and Methods: This integrated review updates the epidemiological data on PA, summarizes the existing evidencebased PA guidelines, describes the global magnitude of inactivity, and finally describes the rationale for action. The first section updates the epidemiological evidence for reduced cardiometabolic risk, reduced risks of falls, the burgeoning new evidence on improved cognitive function and functional capacity, and reduced risk of depression, anxiety, and dementia.
This is followed by a summary of population prevalence studies among older adults. Finally, we present a “review of reviews” of PA interventions delivered from community or population settings, followed by a consideration of interventions among the “oldest-old,” where efforts are needed to increase resistance (strength) training and balance.
Results: This review identifies the global importance of considering “active aging” beyond the established benefits attributed to noncommunicable disease prevention alone.
Implications: Innovative population-level efforts are required to address physical inactivity, prevent loss of muscle strength, and maintain balance in older adults. Specific investment in healthy aging requires global policy support from the World Health Organization and is implemented at the national and regional levels, in order to reduce the burden of disease and disability among older adults.