Study Overview
Objective. To evaluate the association between long-term exercise interventions (duration ≥ 1 year) and risks of falls, injurious falls, multiple falls, fractures, hospitalization, and mortality in older adults.
Design. A systematic review of randomized controlled trials (RCTs) with preplanned meta-analysis was conducted to investigate the association between long-term exercise interventions and falls and fall-related adverse outcomes in adults older than 60 years. A literature search using electronic databases, including PubMed, Cochrane Central Register of Controlled Trials, SportDiscus, PsychInfo, and Ageline, was performed between February 20 and March 5, 2018. Studies selected were RCTs with exercise duration of 1 year or longer, where effects of exercise intervention were compared with a comparator group of participants aged 60 years or older. Articles were independently screened, abstracted, and assessed for risk of bias by 2 raters, who resolved divergences in data extraction and synthesis via in-person meetings.
Setting and participants. A total of 46 studies (22,709 participants; median of 203 participants per study) were included in the review and 40 studies (21,868 participants) were included in the meta-analysis. The participants’ mean age was 73.1 ± 7.1 years, and 66.3% (15,054 participants) were women. Studies were mostly conducted in Europe (n = 15), North America (n = 13), and Oceania (n = 10). Multicomponent training involving multiple exercises (eg, aerobic, strength and balance; 29 RCTs) was the most common intervention modality, followed by aerobic (8 RCTs) and strength (5 RCTs) training. Exercise interventions had a mean frequency of 3 times/week, with each session lasting approximately 50 minutes, and were administered at a moderate intensity. The average compliance rate with exercise training was 65%. Comparator groups were often active controls that ranged from attention controls to more intensive interventions.
Main outcome measures. The 6 binary outcomes investigated were fallers who fell at least once, multiple times, or at least twice; fractures; hospitalization; and mortality. Estimates of outcomes were combined using risk ratios (RRs) using DerSimonian and Laird’s random-effects model (Mantel-Haenszel method). Heterogeneity was evaluated using I2 statistics, and trials with low rates of compliance (< 30%) with exercise intervention or high attrition (> 40%) were excluded in primary analyses.
Main results. Exercise training significantly reduced the risk of falls by 12% (n = 20 RCTs; 4420 participants; RR, 0.88; 95% confidence interval [CI], 0.79-0.98) and injurious falls by 26% (9 RCTs; 4481 participants; RR, 0.74; 95% CI, 0.62-0.88), and reduced the risk of fractures by 16% (19 RCTs; 8410 participants; RR, 0.84; 95% CI, 0.71-1.00; P = 0.05). Exercise training did not decrease the risk of multiple falls (13 RCTs; 3060 participants; RR, 0.86; 95% CI, 0.68-1.08), hospitalization (12 RCTs; 5639 participants; RR 0.94; 95% CI, 0.80-1.12), or mortality (29 RCTs; 11,441 participants; RR 0.96; 95% CI, 0.85-1.09). Sensitivity analyses yielded similar results, with the exception of the fixed-effect meta-analysis for the risk of fracture that showed a significant effect of long-term exercise training (RR, 0.84; 95% CI, 0.70-1.00; P = 0.047). Meta-regression analysis on mortality and falls suggested that exercise frequency between 2 and 3 times per week was optimal and beneficial.
Conclusion. Long-term exercise training of 1 year or longer in duration is associated with a reduction in falls, injurious falls, and fractures in older adults. Moreover, moderate intensity, multicomponent exercise training performed 2 to 3 times weekly is likely safe and effective in this vulnerable population.
Commentary
Falls are exceedingly common (1 in 3 older Americans fall each year) and are the leading cause of fatal and nonfatal injuries in persons over the age of 65 years.1,2 While fall prevention is a public health priority and a topic of interest in many research studies, there are important gaps in knowledge regarding optimal strategies to prevent falls and fall-related injuries in this high-risk population. The study reported by de Souto Barreto and colleagues provides new insights to address several of these gaps and may have a significant impact on the clinical practice of fall prevention in geriatric medicine.