Exercise in Older Women: Effects on Falls, Function, Fear of Falling and Finances

Functional decline predisposes older adults to falls and resulting injuries, which are serious and common medical problems experienced by older adults. The costs of falling are high, both to the individual and to society.

The thesis and its original publications are based on a randomized, controlled trial conducted between April 2010 and March 2013 at the UKK Institute for Health Promotion Research, Tampere, Finland. The purpose of the study was to examine risk factors for falling, including body composition, physical functioning and fear of falling in home-dwelling older women. The study evaluated the effects of supervised multimodal group exercise on physical functioning, falls, fall-related injuries and fear of falling, and its cost-effectiveness from a societal perspective.

Of all 70‒80-year old women from Tampere invited for the study (n = 9730), 409 women who fulfilled the inclusion criteria were randomly assigned to exercise (EX) or control (CON) groups. EX attended supervised group training classes 2 times a week for the first 12 months, and once a week for the subsequent 12

months of the 24-month intervention, with home exercises to be practiced on the remaining days. Training was progressive and consisted of strength, balance, agility and mobility exercises. CON were asked to maintain their pre-study levels of physical activity throughout the trial.

Physical functioning (isometric leg extension strength, walking speed, Timed Up and Go (TUG), chair stand time, backwards walking), fear of falling (FES-I) and physical activity were assessed at baseline, at 6, 12, 18 and 24 months. Activities of daily living (ADL), instrumental ADL (IADL) and outdoor mobility were assessed at baseline and 24 months. Body composition was measured at baseline, 12 and 24 months. Falls were monitored with fall diaries returned monthly. Fall-related health services utilization was assessed from patient medical records over 24 months. Prevalence of sarcopenia was determined using consensus diagnostic criteria.

Cross-sectional analysis of baseline data included independent samples t-tests and multinomial logistic regression. Intervention effects on physical functioning were estimated by LMM and GLMM. Negative binomial regression and Coxregression models were used to evaluate falls and fallers in each group. Costeffectiveness was expressed in terms of the incremental cost-effectiveness ratio, with bootstrapping techniques to estimate uncertainty. All analyses were done according to the ITT principle.

Sarcopenia prevalence was only 1‒3% in this cohort, while 69% reported at least a moderate fear of falling.  Muscle mass and derived indices of sarcopenia were not significantly related to measures of physical functioning. Difficulties in IADL, balance and outdoor mobility contributed independently to a greater fear of falling.

Training compliance for group and home exercise was 73% (range 0% to 97%) and 66% (range 0% to 100%) respectively, with no severe adverse effects or injuries due to the training. At the end of the intervention, there were no significant changes in ADL, IADL or mobility scores, nor were there significant differences between groups. The mean total body lean mass decreased slightly in both groups, but more in CON compared with EX (p=0.048) (peak difference 0.5% at 24 months). EX engaged in a significantly greater amount of at least moderateintensity physical activity per week (p=0.003). Isometric leg extension strength improved significantly (p<0.001) in EX (peak difference 15.5% at 18 months) compared with CON. Fast walking speed improved in EX, and declined in CON (p=0.003) (peak difference 4.3% at 24 months). There were no significant changes or differences between the groups in the TUG test. Chair stand time reduced significantly (p=0.016) in EX compared with CON (peak difference 5% at 24 months). EX showed a significantly greater probability of completing the backwards walking test compared with CON (p<0.001).

There was no significant difference between groups in the total falls incidence rate (IRR 1.0, 95% CI 0.79 to 1.26). However, the number of medically-attended injurious falls (IRR 0.45, 95% CI 0.27 to 0.78, p=0.004), and medically-attended fallers (HR 0.45, 95% CI 0.26 to 0.77, p=0.004) was significantly lower in EX compared with CON. There were no overall changes or differences between groups in FES-I scores (p=0.082). The data suggested 63.4% probability that each injurious fall avoided per person-year required an additional cost of € 191. At a willingness to pay of € 2,240 per injurious fall prevented, there was a 95% chance of the exercise intervention being cost-effective in this population.

In conclusion, sarcopenia prevalence is low in community-dwelling older Finnish women, while fear of falling is common. Multimodal group exercise improved physical functioning and prevented age-related functional decline. Although the intervention did not result in a reduced rate of falls, it reduced fallrelated injuries requiring medical treatment. Exercise training was safe and feasible, required only modest investments for preventing injurious falls, and in some cases may even be cost saving.


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University of Tampere