Summary:
Deborah Jehu, PhD, highlights strategies for promoting physical activity while preventing falls in older adults, emphasizing individualized care, interdisciplinary approaches, and evidence-based interventions to enhance mobility, reduce fall risk, and address cognitive and environmental factors.

Key Takeaways:

  1. Physical Activity vs. Fall Risk: Regular physical activity, especially strength and balance training, outweighs the risk of falls and is crucial for older adults to prevent both injurious and non-injurious falls.
  2. Comprehensive Assessments: Falls-risk assessments should address multifactorial domains (e.g., balance, cognition, and environment), with tools like the Montreal Cognitive Assessment and executive function tests to predict and mitigate fall risk.
  3. Targeted Interventions: Tailored interventions, such as wearing protective gear, refining home safety, and encouraging enjoyable physical activities, improve adherence while reducing sedentary behavior and fear of falling.

Deborah Jehu, PhD, is an assistant professor in the Interdisciplinary Health Sciences Department at Augusta University in Georgia. Her research aims to generate new insights into refining therapeutic interventions, refining falls-risk assessments, and providing a better overall understanding of cognition and mobility in aging populations. She has worked with a wide variety of aging populations, such as: healthy older adults, and older adults who fall, as well as those with total knee arthroplasty, Parkinson’s Disease, stroke, mild traumatic brain injury, and mild cognitive impairment. Here, she shares with Physical Therapy Products her thoughts on promoting patients’ physical activity and preventing falls. 

Injuries can occur during any physical activity, including pickleball. However, the evidence still suggests that being physically active is more protective of falls and injurious falls than not being physically active [1]. That means physical activity outweighs the risks that it may pose in terms of falling. 

There is a strong relationship between bone strength and muscle strength [2]. Therefore, 

engaging in physical activity that targets strength (and balance) is protective against injurious falls as well as non-injurious falls [1].

Physical therapists should advise older adults not to engage in risky behaviors, such as climbing tall ladders or climbing on roofs, because they can increase the likelihood of injurious falls. Risky behaviors are more common in older males than older females. This is especially advisable for older adults who have a mismatch in their perceived versus actual balance ability. 

However, physical therapists should be careful when they advise older adults to not engage in certain activities because it can lead to overall activity restriction. Physical therapists should instead encourage exercise and physical activity that targets lower-body strength and balance as a way to reduce the risk of falls. Here is a list of evidence-based effective fall prevention interventions: https://www.cdc.gov/falls/interventions/falls-compendium.html. 

It’s great if clients take up an active hobby that could help decrease their falls risk. But then, as with any sport, there is the potential for injury. What advice do you have for physical therapists who want to help their clients prevent pickleball injuries? Are there certain techniques or exercises you would recommend? 

With any sport, exercise, or physical activity, there is a risk of falling. However, the risk of falling is greater for those who are not active [3]. To my knowledge, no research study has examined the effectiveness of pickleball in reducing falls; however, recent research specifically examining the effects of contact sports on falls demonstrated inconclusive effectiveness [4], likely due to the lack of research in this area. Notably, older adults need to engage in regular exercise and physical activity that they enjoy to increase adherence, wear appropriate footwear, get enough sleep, and stay hydrated. 

To that end, I feel it’s important to inform older clients about best practices for exercise-based fall prevention interventions. To promote exercise and physical activity, I suggest physical therapists have a conversation with their older clients about physical activities that they enjoy doing that still align with best practice standards for fall reduction. 

It’s helpful to employ physical activity coaching to facilitate scheduling exercise or physical activity into clients’ daily life (e.g., coaching on scheduling exercise or physical activity) and to overcome barriers (e.g., finding a solution to physical inactivity during inclement weather, holidays, etc.) to help older adults increase exercise and physical activity engagement. Therapists can also utilize physical activity coaching apps to encourage regular physical activity and exercise engagement, as well as track progress over time.

To prevent fall-related pickleball injuries, I would encourage their older clients to wear elbow and knee pads to avoid scrapes and bruises. Therapists could also inform their clients of safe landing strategies to reduce the likelihood of fractures, which involve squatting, elbow flexion, forward rotation, martial arts rolling, relaxed muscles, and a stepping strategy [5]. Another options is encouraging at-risk clients to wear hip protectors, which have been shown to reduce hip fractures when they are worn. 

For clients who are wary of physical activity because of a fear of falling, or falling again, how can physical therapists work with them to manage their fear so it doesn’t unnecessarily prevent them from moving, exercising, and living their lives? 

Both cognitive behavioral therapy [6] as well as exercise [7] have been shown to reduce fear of falling among older adults. Cognitive behavioral therapy is a psychological treatment that involves learning to recognize one’s distortions in thinking, gaining a better understanding of the behavior, using problem-solving skills to cope with difficult situations, learning to develop a greater sense of confidence in one’s abilities, and exposure therapy [6]. 

Based on your research, what are the most important behaviors, exercises, and techniques for physical therapists to consider instructing their clients to do to prevent falls, especially recurring falls? 

It is important to note that not all exercise programs reduce falls. For community-dwelling older adults, specifically engaging in challenging lower-body strength and balance training 3x/week indefinitely reduces falls by about 33%. These types of programs are cost-saving for the healthcare system [8]. A list of evidence-based effective fall prevention interventions can be found here: https://www.cdc.gov/falls/interventions/falls-compendium.html.

Active community-dwelling older adults who meet or exceed physical activity guidelines (i.e., 150 minutes of moderate-to-vigorous physical activity [9], which can include brisk walking) can significantly reduce the risk for injurious and non-injurious falls compared to older adults who do not meet these guidelines (i.e., <150 minutes/week) [3]. However, engaging in brisk walking programs can be dangerous for frail older adults because brisk walking may promote rushing and missing important cues in the environment [8]. Walking at a normal pace is recommended for frail older adults for general health benefits, but walking at a normal pace as an intervention alone does not prevent falls [8].

Similarly, older adults who are more sedentary are more likely to fall [10]; therefore, I recommend physical therapists encourage their older patients to engage in regular sedentary breaks to reduce sedentary behavior. 

For older adults who experience recurrent (more than 1/year) or an injurious fall, physical therapists can recommend that their patients see a geriatrician who can provide clinical management recommendations (e.g., medication changes; exercise prescription; referrals to other healthcare professionals such as an eye doctor who updates prescription lenses; lifestyle modifications such as reducing alcohol intake), as this has been shown to reduce falls compared to not seeing a geriatrician [11].

Home hazard reduction (e.g., installing grab bars in bathrooms, removing loose carpeting) has been effective at reducing falls among older adults who are at high risk for falling (e.g., those needing help with activities of daily living, who have had a recent hospitalization, or who have fallen in the last year), but it not effective for those at low risk for falling [12].

Are there types of falls-risk assessments that you find to be most beneficial for older patients, or more specific patient populations in this age group? 

Falls-risk assessments should be comprehensive and cover a wide variety of domains because falls are oftentimes multifactorial. There are seven different domains of fall risk: balance and mobility; 2) environmental; 3) psychological; 4) medical; 5) medication; 6) sensory and neuromuscular; and 7) sociodemographic. Older adults may have a greater risk for falls in one or more of these domains. Therefore, an interdisciplinary team of healthcare professionals working together to individualize fall prevention interventions may be needed. 

For example, a physical therapist may be needed to provide exercise prescription, an occupational therapist for reducing home hazards, an optometrist to update prescription lenses, and a physician to adjust medications. The older adult also plays an important role in informing their healthcare professional team about fall events, changes in risk factors for falls, as well as providing input on preferences for targeted intervention strategies [13].

Are there certain falls-risk assessments that you wish more physical therapists knew about and used more often? When and why should they be used? 

Many physical therapists commonly overlook cognitive testing, even when they suspect that their older client has experienced cognitive decline. However, subjective cognitive complaints, mild cognitive impairment, and dementia increase the risk of falls. 

The Montreal Cognitive Assessment is a measure of global cognition that has predicted future falls and can be added to physical therapists’ assessment battery that has known cut-off scores. Poor executive function also consistently predicts future falls [14]. Measures of executive function that can be added to physical therapists’ assessment battery can include measures such as the Digit Symbol Substitution Test, Color-Word Stroop, Trail-Making Test, Forward Digit Span Test, and/or Backward Digit Span Test. 

Aerobic and resistance training have been shown to improve cognitive functioning. Physical therapists treating older adults with cognitive decline can also suggest that their older clients stimulate their brains by engaging in activities such as brain games, learning a new language, or learning a new instrument. Older clients who appear to have dementia but have not been diagnosed should be referred to a neurologist for treatment.

Do you have any tips for refining falls-risk assessments to better meet client needs?

Standardization of multifactorial person-centered valid and reliable falls-risk assessments is important. Ensuring that falls are consistently documented in patients’ charts is important, especially for researchers conducting retrospective chart reviews. Also, ensuring that the testing battery does not change over time within and across patients is needed to track and compare progress. 

As mentioned above, falls are oftentimes multifactorial. As such, multiple healthcare professionals are often needed to reduce fall risk. Therefore, it’s important for physical therapists to provide appropriate referrals to other healthcare professionals when needed to tailor their care.

Some patient groups tend to experience fewer referrals, such as those with low socioeconomic status, African Americans, and those with cognitive impairment. This results in poorer healthcare outcomes. Providing referrals for all patient groups is important across social determinants of health.

Featured image: Dreamstime

References

1.              Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1750-1758. doi:10.1136/bjsports-2016-096547 

2.              Yang FZ, Jehu DAM, Ouyang H, Lam FMH, Pang MYC. The impact of stroke on bone properties and muscle-bone relationship: a systematic review and meta-analysis. Osteoporos Int. 2020;31(2):211-224. doi:10.1007/s00198-019-05175-4

3.              Kwok WS, Khalatbari-Soltani S, Dolja-Gore X, et al. Leisure-Time Physical Activity and Falls With and Without Injuries Among Older Adult Women. JAMA Netw Open. 2024;7(1):e2354036. Published 2024 Jan 2. doi:10.1001/jamanetworkopen.2023.54036

4.              Valdés-Badilla P, et al., Effectiveness of Olympic Combat Sports on Balance, Fall Risk or Falls in Older Adults: A Systematic Review. Biology (Basel), 2022. 11(1).

5.              Moon Y, Sosnoff JJ. Safe Landing Strategies During a Fall: Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2017;98(4):783-794. doi:10.1016/j.apmr.2016.08.460

6.              Liu TW, Ng GYF, Chung RCK, Ng SSM. Cognitive behavioural therapy for fear of falling and balance among older people: a systematic review and meta-analysis. Age Ageing. 2018;47(4):520-527. doi:10.1093/ageing/afy010.

7.              Kendrick D, Kumar A, Carpenter H, et al. Exercise for reducing fear of falling in older people living in the community. Cochrane Database Syst Rev. 2014;2014(11):CD009848. Published 2014 Nov 28. doi:10.1002/14651858.CD009848.pub2

8.              Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1750-1758. doi:10.1136/bjsports-2016-096547

9.              WHO, Global Status Report on Physical Activity. 2022: Geneva.

10.           Canever JB, Danielewicz AL, Oliveira Leopoldino AA, Corseuil MW, de Avelar NCP. How Much Time in Sedentary Behavior Should Be Reduced to Decrease Fear of Falling and Falls in Community-Dwelling Older Adults?. J Aging Phys Act. 2021;30(5):806-812. Published 2021 Dec 15. doi:10.1123/japa.2021-0175

11.           Davis JC, Dian L, Parmar N, et al. Geriatrician-led evidence-based Falls Prevention Clinic: a prospective 12-month feasibility and acceptability cohort study among older adults. BMJ Open. 2018;8(12):e020576. Published 2018 Dec 4. doi:10.1136/bmjopen-2017-020576

12.           Clemson L, Stark S, Pighills AC, et al. Environmental interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2023;3(3):CD013258. Published 2023 Mar 10. doi:10.1002/14651858.CD013258.pub2

13.           Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative [published correction appears in Age Ageing. 2023 Sep 1;52(9):afad188. doi: 10.1093/ageing/afad188] [published correction appears in Age Ageing. 2023 Oct 2;52(10):afad199. doi: 10.1093/ageing/afad199]. Age Ageing. 2022;51(9):afac205. doi:10.1093/ageing/afac205

14.           Jehu DA, Davis JC, Barha CK, et al. Sex Differences in Subsequent Falls and Falls Risk: A Prospective Cohort Study in Older Adults. Gerontology. 2022;68(3):272-279. doi:10.1159/000516260