Walking Program Insufficient To Reduce Risk of Falls in Elderly

MedicalResearch.com Interview with:
Alexander Voukelatos BSc, BA, MA(psych), PhD

Healthy Populations Program Manager
Health Promotion
Sydney Local Health District and Conjoint Lecturer
School of Public Health and Community Medicine
University of NSW

Medical Research: What is the background for this study?

Response:Falls in older people has been a significant public health issue in high income countries for several decades now. We know that if current trends continue, given that more people will be living for longer, falls will be an even bigger issue in the not too distant. Falls are not an inevitable part of ageing, and in fact many falls can be prevented relatively simply by increasing physical activity.

For over 15 years we’ve known that physical activity is one of the most effective ways of reducing the risk of falls in older people living in the community; since the publication of the first Cochrane review on Interventions for preventing falls in the elderly by Gillespie and colleagues. [1]  I know that Health Departments here, in Australia, and in New Zealand – as I suspect has been the case in many high income countries – have invested a lot of resources over the past few decades into reducing falls-related hospital admissions in older people. Much of this going into promoting and funding physical activity programs for older people.

However, this investment has had very little if any impact on falls-related hospital admissions in older people. There may be several reasons we haven’t seen any difference in these rates. In New South Wales – Australia’s most populous state –  we know that physical activity rates amongst older people have actually risen by about 15% between 1998 and 2005,[2] the most popular activity by far being walking,[3] yet we haven’t see any corresponding change in falls-related hospitalization rates. Perhaps there has not been enough time for these programs to have made an impact on hospitalization rates, or perhaps the change in physical activity levels is insufficient to make an impact on these rates.

Another possibility could be that while we’ve seen an increase in physical activity in older people perhaps its not the kind of physical activity that results in a reduction in falls. Sherrington and colleagues [4] reviewed effective physical activity interventions for preventing falls in older people and found they had several elements in common: a) the physical activity included balance challenging exercise i.e. exercises taking participants to the limits of their stability, b) at least 50 hours of accumulated activity was needed, and c) no walking was included in the exercises. So we know not all types of physical activity will be equally effective in reducing the risk of falling. There is some disagreement in the literature about walking.

There are several studies that included walking as part of the intervention and showed a reduction in falls in older people. Other studies supported the conclusions made by Sherrington that walking is not associated with a reduction in falls. All of these studies included walking as a component of an intervention which makes it difficult to figure out what effect walking specifically has on falls rates.

This is were our study comes in. We wanted to investigate the effectiveness of a walking program on falls in older people, specifically sedentary older people, who we presumed would get the most benefit from becoming more physically active.

We developed a walking program specifically for sedentary older people, that they could do themselves in their own time, at their preferred locale. The aim of the program was to get participants walking for at least 150 minutes per week at a brisk pace. The program comprised of four parts: the first part focused on increasing the frequency of walks, the second part focused on getting participants to walk for at least 150 minutes per week, followed by walking for 150 minutes at a brisk pace, while the final part focused on supporting participants in maintaining their walking levels and incorporating walking as part of their daily activities.

Medical Research: What are the main findings?

Response: The important thing about this study is that it is only one study, using a particular walking program with a specific sub-set of older people. Overall, we found no evidence that our walking program is associated with a reduction (or increase) in falls rates in the study participants. The walking program did however increase study participants’ levels of general physical activity as well as walking levels.

These results can be generalized to a some degree. However, the problem may be because our specific walking program was ineffective in reducing falls rather than walking in general. Results did indicate that the walking program had no impact balance. However, other effective falls prevention activities such as Tai Chi have also had no impact on balance [5]. Results may also be better generalized to other sedentary older people rather than older people in general. However, as walking had no effect on falls amongst sedentary older people – who one would imagine would benefit from becoming more active -, it is highly unlikely that walking would have an effect on falls in more physically active older people.However, on closer inspection there were some interesting trends. Note that by trends I mean there was no statistical support for the following conclusions but there was some consistency in the data that suggests there maybe something going on (something for future research). The data indicated that for participants aged 65-74 years walking had non-significant decrease in falls, whereas for participants aged 75 years or more walking had a non-significant increase in the the risk of falls. The key words here are non-significant. This study was not powered to examine the data stratified by age group. However these trends may be explained if we consider age-group a proxy for frailty (of course this is not conclusive as there will be some 65-74 year olds who are frail, and indeed some people over 75 years who are not frail) For the more frail participants (i.e. 75+ year olds) walking actually increased their risk of falls by exposing them to environmental falls risk factors – eg. uneven surfaces, slippery paths – which they were too frail to negotiate. On the other hand the less frail participants (65-74 year olds) even though they were exposed to more environmental falls hazards they were able to negotiate the hazards and in time reduce their risk of falling. These two opposing effects may have cancelled each other out thus resulting in the null effect for the overall study. This is purely speculative however

 

Medical Research: What should clinicians and patients take away from your report?

Response: The take away message from this study is that walking may not be a sufficient activity to reduce the risk of falls in older people. If a clinician or anyone else is concerned about someone’s risk of falling walking is probably not going to do much to address this.

However, walking is still a highly effective and very important activity for addressing many chronic diseases in older people. And walking can still play an important role in reducing falls as a way of increasing activity levels for sedentary older people who, once they become more active, can then participate in proven falls prevention activities such as tai chi.

I would also recommend that clinicians use their judgment in prescribing walking for people over 75 years of age.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: This study shows that the relationship between walking and falls is not straight forward. Future studies might consider planning a stratified analysis based on age-groups, or level of frailty to see if age is a modifying variable. Also future studies could use different types of walking such as obstacle walking or hiking/bushwalking which present many falls hazards to walker – the idea being that if the walker can learn to safely negotiate these high-level falls hazards then that will confer a beneficial effect in negotiating more moderate falls hazards typically found in their local environment.

[1] Gillespie LD, Gillespie WJ, Cumming R, Lamb S, Rowe BH. Interventions for preventing falls in the elderly (Cochrane Review). The Cochrane Library 1997, Issue 4.
[2] Chau J, Smith B, Chey T, Merom D, Bauman A. Trends in population levels of sufficient physical activity in NSW, 1998 to 2005: Summary report. Sydney, NSW: NSW Centre for Physical Activity and Health (CPAH); January 2007. Report No. CPAH06-001b
[3] Merom D, Pye V, Macniven R, Van der Ploeg H, Milat A, Sherrington C, Lord S, Bauman A. Prevalence and correlates of participation in fall prevention exercise/physical activity by older adults. Prev Med 2012; 55(5): 613-7.
[4] Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. NSW Public Health Bull 2011, 22 (3-4): 78-83.

Citation:

The impact of a home-based walking programme on falls in older people: the Easy Steps randomised controlled trial
Alexander Voukelatos, Dafna Merom, Catherine Sherrington, Chris Rissel, Robert G. Cumming, and Stephen R. Lord

Age Ageing first published online January 8, 2015 doi:10.1093/ageing/afu186

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