1. The Effects of Balance Exercise on Fall Prevention
with the Elderly in Long-Term Care Settings
Pace University, College of Health Professions, Lienhard School of Nursing
EliyahuAbramowitz
MeaganAlger
Miriam Becher
Marissa Brown
Elsa Carlo
Bianca Diaz
Yaakov PerlsteinPICO: For patients ages 65 and over in long-term care settings who are at risk for falls, will a
nurse-led, twice-weekly exercise program aimed at improving muscle strength and balance for a
duration of six months reduce the incidence of falls, compared to those of the same population who do not complete the program?
BACKGROUND
The elderly have a disproportionately higher fall rate
>25% than the general population (Gregory & Watson,
2013).
Muscle weakness, balance disorders, fear of falling
and previous falls may increase fall rates (WHO,
2009).
Elderly living in long-term care facilities have a 30 -
50% fall rate and a 40% recurrence rate (CDC, 2014).
More than 1/3 of adults 65 years and older fall every
year (WHO, 2009). After adjusting for inflation, falls
resulted in medical costs of an estimated $30 billion in
2012 (CDC, 2014).
20-30% of these falls lead to severe and potentially
fatal conditions (WHO, 2009).
RESEARCH LITERATURE REVIEW PROPOSED PRACTICE CHANGE CHANGE PROCESS
Educating all healthcare personnel throughout the
local VA hospital, regarding the high incidence of falls
among elderly patients and the importance of
prevention, will create a sense of urgency and
environment for change (Stragalas, 2010).
Create a coalition of diverse nursing professionals
from all levels of experience throughout the local VA.
The coalition’s mission is to empower both healthcare
and non-healthcare professionals to participate in
creating and facilitating practice improvement
strategies that decrease incidence of falls. The vision
is to reduce incidence of falls in hospitals, while
reducing hospital costs and increasing quality of life
of elderly patients.
Prior to implementation of the exercise program,
selected nurses will be trained for three months in
instructing classes on strength and balance for
geriatric individuals.
Patient education of fall risks and benefits of a
balance-improving exercise regimen will be employed
via literature and patient-nurse communication.
• • Low-impact exercise and muscle strengthening
reduces the risk of falls, incidence of falls, and
severe injury associated with falling (Cakar et al.,
2010).
Current clinical guidelines recommend that nurses,
implement multifactorial fall prevention interventions,
including physical training (Registered Nurses’
Association of Ontario, 2011).
Exercises designed to facilitate balance
improvement increases participants self-efficacy in
relation to falls, and may reduce the rate of falls
within a six-month interval (Clemson, et al., 2010).
The effectiveness of tai chi training as compared to
other training methods was unclear; it is among the
many forms of balance improvement exercises that
reduces the incidence of falls among the elderly
population (Maciaszek & Osiński, 2010).
• • Implementation of a nurse led twice weekly exercise
program for patients aged 65 and older in long term
care settings, found to be at risk for falls using the
Morse Fall Scale.
•
• • Exercises will be aimed at improving coordination,
balance, stability, gait, equilibrium and lower limb
muscle strength.
•
•
• Program will be for a duration of six months.
• •
• Assessments will be made at intervals of three and
six months using the following scales: ‘Timed Up
and Go’, ‘Berg Balance Scale’, ‘Outcome
Expectations for Exercise Scale’, and ‘Falls Efficacy
Scale-International’.• •
•
•
•
Music will be played throughout the class.
Ongoing practice of exercises will be encouraged
through patient education.
•
MAJOR RECOMMENDATIONS
Direct measurements of fall risks, balance, gait, self-
efficacy and fear of falling pre-intervention phase,
third month interval and post -intervention phase
(sixth month interval).
Regimen will include warm-up exercises, lower limb
strength training, light aerobics, and cool down
sessions with breaks in between (Song et al., 2014).
EVALUATION•
http://www.prnewswire.com/news-releases/b-shoe-footwear-helps-seniors-maintain-balance-avoid-
falls-236542921.html
• A baseline appraisal of all newly admitted patients
will be made utilizing the institution’s standard fall
risk assessment tool in conjunction with a falls self-
efficacy measurement.
SEARCH STRATEGY
Databases used include the following:
•
1) CINAHL
2) Cochrane
3) CDC
4) PubMed
5) EBSCO-Medicine
6) NIH
• Patients who receive a score identifying them as
being at high risk for falls will be invited to participate
in a 6-month long nurse-led exercise program
targeting these goals.
http://ridfat.blogspot.com/2013/01/balance-exercises-for-seniors.html
• Physical activities will target
the lower extremities to enhance
balance, gait ability,
self-efficacy levels and
decrease fear of falling
(Wong et al., 2009).
REFERENCES
Cakar, E., Dincer, U., Kiralp, M., Cakar, D., Durmus, O., Kilac, H., & ... Alper, C. (2010). Jumping combined exercise programs reduce fall risk
and improve balance and life quality of elderly people who live in a long-term care facility. European Journal Of Physical And
Rehabilitation Medicine, 46(1), 59-67. Level II: Randomized Controlled Trial
Centers for Disease Control and Prevention. (2013). Timed Up and Go Test. Retrieved March 22, 2014, from http://www.cdc.gov/
homeandrecreationalsafety/pdf/steadi/timed_up_and_go_test.pdf
Centers for Disease Control and Prevention. (2014). Home & Recreational Safety. Retrieved October 22, 2014, from http://www.cdc.gov/
homeandrecreationalsafety/Falls/steadi/index.html
Clemson, L., Singh, M., Bundy, A., Cumming, R. G., Weissel, E., Munro, J., & ... Black, D. (2010). LiFE Pilot Study: A randomised trial of
balance and strength training embedded in daily life activity to reduce falls in older adults. Australian Occupational Therapy Journal,
57(1), 42-50. doi:10.1111/j.1440-1630.2009.00848.x Level II: Randomized Controlled Trial
Dykes, P., Carroll, D., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., & ... Middleton, B. (2010). Fall prevention in acute care hospitals: a
randomized trial. JAMA: Journal of the American Medical Association, 304(17), 1912-1918. doi:10.1001/jama.2010.1567 Level II:
Randomized Controlled Trial
Gregory, H., & Watson, M. (2009). The effectiveness of Tai Chi as a fall prevention intervention for older adults: a systematic review.
International Journal Of Health Promotion & Education, 47(3), 94-100. Level I: Systematic Reviews
Joshua,A., D'Souza, V., Unnikrishnan, B., Mithra, P., Kamath, A., Acharya, V., & Venugopal, A. (2014). Effectiveness of progressive resistance
strength training versus traditional balance exercise in improving balance among the elderly - a randomised controlled trial. Journal Of
Clinical And Diagnostic Research: JCDR, 8(3), 98-102. doi:10.7860/JCDR/2014/8217.4119 Level II: Randomized Controlled Trials
Logghe, I., Zeeuwe, P., Verhagen,A., Wijnen-Sponselee, R., Willemsen, S., Bierma-Zeinstra, S., & ... Koes, B. (2009). Lack of effect of Tai Chi
Chuan in preventing falls in elderly people living at home: a randomized clinical trial. Journal Of The American Geriatrics Society, 57(1),
70-75. doi:10.1111/j.1532-5415.2008.02064.x Level II: Randomized Controlled Trials
Maciaszek, J., & Osiński, W. W. (2010). The Effects of Tai Chi on Body Balance in Elderly People — A Review of Studies from the Early 21st
Century. American Journal Of Chinese Medicine, 38(2), 219-229. Level I: Systematic Reviews
Registered Nurses’ Association of Ontario (RNAO). (rev. 2011). Prevention of Falls and Fall Injuries in the Older Adult. Toronto, ON: Registered
Nurses’ Association of Ontario. Level I: EBP Guidelines
Silveria, L. M. (2009). Compliance with CMS "Never Event" Billing Requirements. Journal Of Health Care Compliance, 11(5), 33-36. Level VII:
Evidence from the Opinion of Authorities
Song, H., Park, S., & Kim, J. (2014). The effects of proprioceptive neuromuscular facilitation integration pattern exercise program on the fall
efficacy and gait ability of the elders with experienced fall. Journal Of Exercise Rehabilitation, 10(4), 236-240. doi:10.12965/jer.140141
Level II: Randomized Controlled Trial
Stragalas, N. (2010). Improving Change Implementation. OD Practitioner, 42(1), 31-38. Level VII: Evidence from the Opinion of Authorities
van Harten-Krouwel, D., Schuurmans, M., Emmelot-Vonk, M., & Pel-Littel, R. (2011). Development and feasibility of falls prevention advice.
Journal Of Clinical Nursing, 20(19/20), 2761-2776. doi:10.1111/j.1365-2702.2011.03801.x Level VI: Descriptive Studies
Wong, A. M., Pei, Y., Lan, C., Huang, S., Lin, Y., & Chou, S. (2009). Is Tai Chi Chuan effective in improving lower limb response time to prevent
backward falls in the elderly?. Age (Dordr.), 31(2), 163-170. doi: 10.1007/s11357-009-9094-3. Level IV: Case Control Studies
World Health Organization. (2009). Global Report on falls prevention in older age (DHHS Publication No. ADM 90-1679). France. Government
Printing Office
• Assessment will be repeated in addition to a ‘Timed
Up and Go’ test (CDC, 2013) at three and six month
intervals of the exercise program. This time frame
was based on several research studies that used a
six-month time frame exercise program with
measurable intervals to gather evidence regarding
fall prevention (Clemson et al., 2010; Joshua et al.,
2014).
http://www.theexpertinstitute.com/case-studies/nursing-home-expert-
witness-opines-on-fall-prevention-protocols-for-high-risk-patients/
• Keywords included: geriatric, elderly, fall, fall
prevention, balance, and exercise.
Delimitations included: English language only,
publication date of 2009 and after, scholarly
systematic reviews, and research articles.
• Program will run twice weekly
for 6 months (Clemson et al.,
2010; Joshua et al., 2014;
Logghe et al., 2009).
•
• Studies identified: 14 scholarly articles, two
systematic reviews, one clinical guideline, and two
expert opinions were chosen based on the amount
of evidence and effectiveness of interventions
relevant to PICO. Best practice recommendations
were consistent among reviewed studies.
http://www.thompsonhealth.com/HealthCareServices/HealthServices/
RehabilitationServices/SportsMedicine/SeniorFitnessTraining.aspx
• Outcome measurement strategy would include falls
self-efficacy, incidence of falls, mobile stability and
gait, muscle strength, and overall quality of life.
• Led by nurses who are trained in physical and
exercise therapy.