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• To recognise the importance of exercise in older people in preventing falls
• To enhance your confidence in promoting exercise programmes suitable for older people
• To contribute towards revalidation as part of your 35 hours of CPD (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Older people who sustain a fall may experience a range of adverse outcomes, such as distress, injury and loss of independence. Falls increase the risk of frailty and frailty increases the risk of falls. Regular exercise is a pillar of falls prevention and can have extensive benefits for older people’s health, well-being and ability to undertake activities they enjoy. As part of the multidisciplinary team, nurses have a pivotal role in implementing exercise-based falls prevention strategies for older people and in encouraging their patients to exercise. This article discusses exercise as a falls prevention strategy in hospital and in the community and supports nurses to develop their knowledge and confidence in promoting exercise in older people.
Nursing Older People. doi: 10.7748/nop.2024.e1452
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Zinyemba V (2024) Exercise as a falls prevention strategy in the care of older people. Nursing Older People. doi: 10.7748/nop.2024.e1452
Published online: 10 January 2024
The aims of this article are to highlight the place of exercise as part of falls prevention strategies in older people and to support nurses to identify ways of improving exercise uptake among their patients to reduce their risk of falls. After reading this article and completing the time out activities you should be able to:
• Explain why the risk of falls increases with age.
• Describe the relationship between falls and frailty.
• Discuss different exercise types and programmes that can be suitable for older people.
• Demonstrate the benefits of exercise to patients and family carers.
• Increase patients’ confidence in undertaking exercise unsupervised at home, where appropriate.
The UK has an ageing population and will have an estimated additional 7.5 million people aged 65 years and over by 2069 (Office for National Statistics 2021). Falls among older people are common, potentially causing distress, injury and adverse health outcomes (National Institute for Health and Care Excellence 2013, Steventon et al 2018). Approximately 30% of people aged 65 years and over, and more than 50% of people aged 80 years and over, fall at least once a year (Office for Health Improvement and Disparities (OHID) 2022).
Falls in hospitals are the most commonly reported patient safety incident, with more than 240,000 reported annually in acute hospitals and mental health trusts in England and Wales (OHID 2022). Falls in inpatient settings can occur in any department or unit; in England in 2021, most fall-related inpatient femoral fractures occurred on medical wards, followed by wards for older people, frailty wards and frailty assessment units and emergency departments (National Audit of Inpatient Falls 2022).
Nurses, educators, managers, leaders and commissioners working in older people’s care need to develop and implement robust and sustainable measures to prevent and manage falls (Rush et al 2017, McKee et al 2021), particularly for those at higher risk or with a history of falls. Furthermore, educating older people and their family carers on falls prevention can increase their awareness of risk factors and prevention strategies, thereby reducing the risk of falls (Heng et al 2020).
Around 10% of people aged over 65 years, and between 20% and 50% of people aged over 85 years, live with frailty (Age UK 2020), a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves (British Geriatrics Society (BGS) 2017). Frailty develops due to a cumulative decline in multiple physiological systems which erodes homeostatic reserve, leading to a state of increased vulnerability to external stressors. In frailty, even relatively minor events such as a fall can trigger disproportionate changes in health status (Clegg et al 2013).
Frailty limits the person’s level of physical activity, causing them to walk more slowly or to find it difficult to mobilise. Older people with frailty often need assistance with activities of daily living such as shopping, cleaning or gardening (Ramsey et al 2021), while some become housebound and dependent on carers (Takagi et al 2015, Schlaff et al 2017). Deconditioning and dependency accelerate muscle weakening and muscle loss in people with frailty, increasing the risk and frequency of falls, the number of hospital admissions following falls and the severity of fall-related injuries (McMillan and Hubbard 2012, Ramsey et al 2021).
Falls are one of the five ‘frailty syndromes’ – which also include immobility, delirium, incontinence and susceptibility to the side effects of medicines – that should raise suspicion that frailty may be present (BGS 2014). In a secondary analysis of data from a study of hospital inpatients aged 70 years or over with cancer and frailty, Kenis et al (2022) showed that level of dependency had increased following one or more falls in more than 50% of participants.
How does exercise help with falls prevention? What are the benefits of exercise for older people? Can you recall older people you have cared for who you helped to undertake regular exercise? How did this work out for them?
• Regular exercise can reduce or prevent muscle weakening, muscle loss and deconditioning in older people and support them to build up muscle strength
• Factors to consider when recommending an exercise programme include the type, mode, intensity and amount of exercise
• Information, training and education are crucial to ensure older people understand the importance of exercise
• Education and training on exercise and its benefits can enhance nurses’ competence and confidence in initiating, monitoring and promoting exercise programmes for older people
Exercise is one aspect of falls prevention in older people. Although the benefits of exercise in older people may not be immediately visible, the longer-term benefits, which may include improvements in general health and quality of life, are well documented (Kumar et al 2016).
Regular exercise can reduce or prevent muscle weakening, muscle loss and deconditioning in older people (Ganz and Latham 2020, Ramsey et al 2021) and can support people to build up muscle strength, particularly in their arms and legs, and improve resistance and endurance (Kumar et al 2016, Schlaff et al 2017, Ganz and Latham 2020). Brach et al (2017) reported a reduction in falls, increased muscle strength and increased gait speed in older people completing twice weekly 50-minute group exercise walks over a six-week period. Exercise also improves blood circulation, reducing the risk of venous thromboembolism (Greenall 2017).
Straight et al (2016), who reviewed randomised controlled trials (RCTs) measuring the effects of resistance training in people aged 50 years or over, concluded that it was an efficacious strategy for improving muscle power in the lower extremities. Meanwhile, Travers et al (2023), who undertook a multicentre RCT in primary care practices with people aged 65 years or over with frailty, found that participants who had received a three-month home-based exercise regimen and advice on daily protein intake experienced improvements in grip, muscle mass, bone mass and levels of physical activity. The researchers concluded that a combination of exercise and dietary protein intake could significantly reduce frailty and improve self-reported health.
Sherrington et al (2017), in an updated systematic review of RCTs comparing fall rates in older people receiving exercise as a single intervention with fall rates in a control group, found that exercise reduced the rate of falls in older people living in the community, including those with Parkinson’s disease or cognitive impairment. However, 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.
Improvements in gait and balance potentially reduce older people’s fear of falling, giving them confidence to continue activities they enjoy (Kumar et al 2016), while building up muscle strength can help people to continue activities such as gardening, walking their dog or spending time with their grandchildren (Schlaff et al 2017). Exercise can be a cost-effective way of improving health outcomes, stimulating people’s minds and motivating them to achieve targets (Kumar et al 2016). Palmer (2022) highlighted that routine exercise can have a positive effect on older people’s psychological well-being, giving them a sense of achievement at reaching their targets.
Read this brief NHS guidance on physical activity in older people: www.nhs.uk/live-well/exercise/exercise-guidelines/physical-activity-guidelines-older-adults How could this guidance inform the care you and your colleagues provide to patients?
Factors to consider when recommending or prescribing an exercise programme include the type, mode, intensity and amount of exercise. Combining aerobic exercises, which increase the rate of oxygen consumption, with resistance exercises has been shown to be optimal for older people to build up and maintain muscle mass while improving endurance (Liu and Fielding 2011). Sherrington et al (2017) found that more than three hours of weekly exercise and balance-challenging exercise had greater effects on reducing the rate of falls in older people living in the community than shorter duration exercise and non-balance-challenging exercise. Straight et al (2016) reported that engaging in more frequent high intensity and high velocity resistance training, such as leg press, resulted in greater muscle mass build up and strength in middle-aged and older adults than engaging in low intensity and less frequent exercises.
To improve strength and balance and avoid falls, OHID (2022) recommends that older people undertake muscle-building activities at least two days a week; these activities could be resistance training, exercising with weights, ball games, circuit training, racket sports or Nordic walking, depending on the person’s ability.
Some people may prefer to exercise in a group or class, which may increase motivation and opportunities for social interaction (Martínez-Velilla et al 2019, Age UK 2022), and which may help people who benefit from having a structure (Brach et al 2017). Chair-based exercise classes offered by Age UK (www.ageuk.org.uk/information-advice/health-wellbeing/exercise/simple-exercises-inactive-adults) are an example of group exercise classes. Other people may prefer to exercise independently at home but may find it challenging to start or be unsure where to start. The Age UK website offers a range of information on how to stay active at home (www.ageuk.org.uk/information-advice/health-wellbeing/exercise).
Box 1 shows advice from Age UK (2022) on gentle exercise for older people at home, which nurses can recommend according to the person’s abilities, needs and risks. Table 1 offers an overview of three exercise programmes that can suit the needs of older people but cannot always be undertaken at home without supervision, depending on the person’s abilities, needs and risks.
| Programme | Aim and/or content | Benefits and barriers |
|---|---|---|
| Gait adaptability training (GAT) |
|
|
| Vivifrail |
|
|
| Pilates |
|
|
Regular standing
If you sit down a lot during the day, try to get up once an hour. If that is not possible, moving your arms and legs for a few minutes will help
Standing up without help
Work towards standing up from a sitting position without using a walker or leaning on someone else:
• Sit on a chair without arm rests, with your arms across your chest
• Lean forward
• Put your weight on your feet while leaning forward
• Stand up by straightening your knees
• Sit down again
• Repeat this as many times as you feel able
• Try to do this exercise 3-5 times a day
Gentle stretches
Try some gentle stretches in bed or a chair every day:
• While sitting or lying, bring your toes towards your shins and then point them towards the floor. Repeat for both feet
• Sitting on a chair, lift your leg up off the seat keeping your knee bent. Return to starting position and lift your other leg. Repeat exercise as you are able
• Sitting on a chair, raise your toes on one side, tighten your thigh muscle and straighten your knee. Hold for about 5 seconds if you can and then slowly relax your leg. Repeat for both legs
• Sitting on a chair with your feet on the floor, bend one knee as much as possible. Repeat for both legs
• Sitting on a stool, let your back drop and become rounded then use your back muscles to straighten your back and arch it (but not too much)
Walking between rooms
If you are steady on your feet, walk from one room to another and back and measure how long it takes. Try to do it a bit faster every day
(Adapted from Age UK 2022)
Watch this video on Pilates: www.youtube.com/watch?v=RgN1mcV45Qw Does the advice and demonstration look clear to you? What precautions would be needed before using Pilates with older people? Are there older people in your care for whom Pilates could be useful? Are there Pilates classes in your local community that you could signpost patients to?
It is crucial to assess the person’s baseline physical function, abilities, needs and risks, particularly their risk of falls, before they start exercising and this must be undertaken by a qualified healthcare professional, usually a physiotherapist. A careful and thorough assessment will inform the development of a suitable exercise programme for the individual (McKee et al 2021).
It is equally important to gain and document informed consent from the person before the start of an exercise session (Nursing and Midwifery Council (NMC) 2018). In older people who may lack capacity, for example due to impaired cognitive function, a mental capacity assessment should be completed, as set out in the Mental Capacity Act 2005. If the person is found to lack capacity but could benefit from an exercise programme, a decision to treat can be made in their best interests and must be documented as such (Department for Constitutional Affairs 2007).
It is important to keep a clear and accurate record of the completion of an exercise intervention (NMC 2018). Documentation should be precise, accurate and up to date, reflecting the level of care given (NMC 2018), including whether the exercise was declined, attempted, partially completed or completed.
An exercise chart can be used to record the level and intensity of exercise, highlighting the person’s achievements and areas where additional support is required. The exercise chart should be documented each time the person completes an exercise session, or declines to exercise, and can be useful to evaluate their progress. Exercise charts should be developed by the multidisciplinary team, including physiotherapists, occupational therapists and doctors, so that all important aspects are considered and captured.
The continuation of exercise after discharge from hospital potentially reduces readmission rates (McKee et al 2021). If it is safe for an older person to undertake exercise unsupervised, they should be encouraged to continue exercising after discharge. Showing them how to record their progress in their exercise chart could encourage them to continue exercising.
Older people in your care may be aware that exercise is good for them but lack motivation or feel unsure where to start. How do you rate your own ability at motivating them? Watch this Age UK video on YouTube to get inspiration: www.youtube.com/watch?v=J_amTAlNbTA
Chen (2010), who explored barriers to regular participation in physical activity among older people in long-term care facilities, found that lack of adequate information, training and education on how to monitor their progress or when to modulate the intensity of exercise contributed to low adherence to exercise programmes. Information, training and education are crucial so that older people understand the importance of exercise, take up an exercise programme and adhere to it.
Chen (2010) noted that fear of falling also contributed to avoidance of and non-adherence to exercise. Kenis et al (2022) demonstrated that more than half of the older people in their study who had a history of falls reported fear of falling, resulting in reduced mobility and increased dependency. Fear of falling reduces people’s confidence to walk or undertake tasks that involve physical activity (Kenis et al 2022). Consequently, older people walk and perform tasks slowly and cautiously and gradually lose confidence in undertaking activities of daily living (Young and Mark Williams 2015). Developing an individualised exercise programme designed to gradually build up the person’s strength and confidence is central to helping them reach their potential and maintain independence.
Some people may lack motivation and need encouragement to undertake exercise, and nurses have an important role in prompting them to do so (Weber and Kelley 2014). A tailored programme that enables the person to increase the duration, intensity and frequency of exercise safely and record their progress and achievements can help to maintain high levels of motivation (McKee et al 2021, Age UK 2022). Family carers can be encouraged to assist the person with exercise or to exercise with them if it is safe and appropriate to do so. Involving family carers is particularly important for an older person who has started an exercise programme in hospital and needs to be encouraged to continue it after discharge (Doyle et al 2021).
Older people with long COVID may be particularly anxious about engaging in physical activity and refrain from walks or group exercise, while long COVID symptoms can reduce their physical capacity to perform tasks, especially if they have a pre-existing health condition (McAuley et al 2023). Daynes et al (2021) demonstrated that if exercise is carried out incrementally there can be a reduction in long COVID symptoms, an increase in physical activity and an improvement in quality of life.
Nurses often lack time to carry out their duties safely, especially on busy medical wards, during winter and as a consequence of staff shortages, which can lead to suboptimal care (Marufu et al 2021). Time pressures often mean that aspects of care considered essential, such as medicine administration, wound care and personal hygiene, are prioritised over those perceived as less important, such as exercise (Drennan and Ross 2019). Considering its benefits, exercise should be regarded as a core component of holistic care and as important as the administration of antibiotics to treat an infection, for example.
In inpatient settings there is a phenomenon that has become known as ‘pyjama paralysis’, meaning unnecessary prolonged bed rest and limited opportunities to engage in physical activity (NHS England 2018, Peate 2018). Unnecessary bed rest and prolonged immobility contribute to deconditioning and potentially increase the risk of falls and falls-related adverse events (Fitzpatrick et al 2019). Nurses need to prompt staff to encourage and assist physically able hospitalised older people to get out of bed in the daytime (NHS England 2018, Peate 2018). The role of nurses includes disseminating accurate, up-to-date and relevant information during handovers about patients’ level of physical ability and what they can and cannot do independently (Bruton et al 2016, Raeisi et al 2019).
Education and training on exercise and its benefits in older people can enhance nurses’ competence and confidence in initiating, monitoring and promoting exercise programmes, while clinical supervision and appraisals can identify gaps in nurses’ knowledge and competence and the measures required to expand their knowledge and competence.
Age increases the risk of falls, and falls can have serious negative consequences on older people’s health and well-being. There is a wealth of evidence on the positive long-term effects of exercise in older people, while regular exercise is one of the pillars of falls prevention. Older people should therefore be encouraged to engage in exercise and be given exercise programmes tailored to their physical abilities and needs.
Barriers to exercise in older people can often be overcome through education and training. Nurses have an important role in motivating older people to exercise and in implementing, with the wider multidisciplinary team, exercise-based falls prevention strategies.
Identify how considering exercise as a falls prevention strategy in the care of older people applies to your practice and the requirements of your regulatory body
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
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