Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please can you tell us a little bit about falls in older people and what tends to cause them?
We often think of tripping over a step edge or pathway obstruction but there can be a range of things that can contribute to a fall. One of the most common is that our ability to balance can be reduced. This means that we don’t recover from a trip and are at more of a risk of losing our balance.
Weak ankles and hips mean that we are at added risk. People can wear shoes and slippers that are ill-fitting and slippery which adds to a shuffling gait. Other people have cataracts that need fixing or maybe are on multiple medications that contribute to dizziness and could be reviewed, at least with a view for a lower dosage.
How frequent are falls in older people? Who is at the highest risk of falls?
About 30% of people over 70 will have a fall this year and the risk of falling increases with age. It is likely we will have a fall sometime in our life but there are things we can do to reduce this risk and to reduce the risk of injury.
Those at highest risk are those who have had a fall, people who have had a recent hospitalisation, have weaker legs, slower walking speed, people taking multiple medications or sleeping tablets over a long period, and people with cognitive impairment.
Your recent research showed that balance and strength training can reduce the number of falls among older people. Please could you give us a brief introduction to what balance and strength training is?
In the LiFE program, movements specifically prescribed to improve balance or lower limb strength are embedded within everyday activities. We introduce repetition as these can be done multiple times each day. We teach a key principal of balance which is to keep challenging your balance and for strength it is to load your muscles.
Examples of strategies to improve balance can include ‘reducing base of support’ which might be standing heel to toe while working at the kitchen bench and be upgraded to one leg standing or ‘Move to limits of sway’ might involve leaning as far as possible to one side (while keeping your back straight) when you are cleaning your teeth.
Examples of strategies to improve strength are ‘on your heel’ which you could prompt yourself to do by placing a mug higher in the cupboard or heel walking between rooms. Another strength strategy is ‘Bend knees’ which can involve squatting to close a drawer or picking something up from a lower level.
All these activities can be learnt and there are many opportunities in daily life to do them. The program is taught by occupational therapists and physiotherapists and upgraded slowly as balance and strength gains are made.
How did your research originate?
The idea came when I was doing another program called Stepping On, a group based falls prevention program which is multifaceted but taught a home based traditional exercise program. Some people struggled with doing the exercises routinely three times a week and I wondered if there could be a different approach to balance and strength training that would work.
How effective was balance and strength training in preventing falls for older people in the LiFE program?
We had a significant reduction of 31% in the rate of falls in LiFE compared to the control group. The program also had significant improvements over the control program in ankle strength, standing balance and walking balance and balance confidence.
What was also exciting is that we had some lovely functional outcomes with significant gains in capacity for daily living task and participation in life situations and social activities.
Your research was on balance and strength training that was integrated into everyday activities. How does this differ from structured exercise programs?
Instead of doing a structured program on a regular time each week, LiFE activities are incorporated throughout the day into daily routines. They are very functional as they are task oriented and we also encourage people to be more physically active.
For example: selecting routes that involve stairs instead of avoiding them; parking the car further away from the shops so you get to walk more; going for a walk after a lunch out with a friend; getting up and changing the television channel instead of using the remote.
This programme relies on bringing into your active memory and planning certain activities until they become habitual and routine. Safety and correct technique are still important just as they are in a traditional exercise program. LiFE provides another choice to traditional balance and strength training.
What plans do you have for further research into this area?
We are interested if LiFE could be useful for specific populations, could those younger-older people start to incorporate LiFE activities and could these be sustained over time.
A group in Perth, West Australia have started doing some translational work to see if it can be incorporated in current aged care services and a group in the US have secured funding to explore its applicability there and to investigate key implementation features with a view to developing fidelity checks for therapists.
There has been a lot of interest worldwide since our publication in the BMJ.
How do you see the future of fall prevention in older people progressing?
We know what works in the general population and we are now refining and starting to test approaches for specific high risk groups. There is still much work in implementing falls prevention and making it accessible to the wider population.
Education and skills building of health professionals and providing relevant resources is also an important part of this process. But we have come a long way since I started working in this area 20 years ago.
Where can readers find more information?
The LiFE participant and therapist manuals will shortly be available from Sydney University Press. They can be contacted on firstname.lastname@example.org
About Professor Lindy Clemson
Lindy Clemson is Professor in Ageing and Occupational Therapy and an NHMRC Career Development Research Fellow at the Ageing, Work & Health Research Unit, The University of Sydney. She is an also an investigator on the Centre of Excellence in Population Ageing Research.
Professor Clemson is an occupational therapist with a PhD in epidemiology. Her specific focus is on the physical environment, functional capacity and adaptation, daily life activity and enabling participation and much of her research has been investigating falls prevention with older people.
She has conducted trials to test the efficacy of interventions, including Stepping On and LiFE, has developed assessments related to healthy ageing and participation and is interested in investigating ways to translate research into practice.