how to prevent fall among elderly population

1. YOGA TECHNIQUES FOR BALANCE AND FALL PREVENTION
Presented by : Divya Singh
Junior Research Fellow
Center for Integrative Medicine and Research
All India Institute of Medical Sciences, New Delhi

2. INTRODUCTION
• A fall is defined as an incident which results in a person
coming to rest accidentally on the ground or floor or other
lower level. Fall-related injuries may be fatal however most are
non-fatal. While all people who fall are at risk of injury, the
age, gender and health of the individual can affect the type and
severity of injury.
• Falls are the second leading cause of unintentional injury
deaths globally. Each year worldwide: an estimated 6,84,000
individuals die from falls; 37.3 million falls are severe enough
to require medical attention.
• Adults older than 60 years of age suffer the greatest number of
fatal falls.(1)
Reference: WHO Falls Available: HTTPs://www.who.int/news-room/fact-sheets/detail/falls (accessed 3.11.2022)

3. BALANCE
• Balance refers to an individuals
ability to maintain their line of
gravity within their Base of
support (BOS).
• It can also be described as the
ability to maintain equilibrium,
where equilibrium can be defined
as any condition in which all
acting forces are cancelled by each
other resulting in a stable balanced
system.

4. BALANCE SYSTEMS
The following systems provides input regarding the body's equilibrium and thus maintains balance.
1. Somatosensory / Proprioceptive System
2. Vestibular System
3. Visual System
The Central Nervous System receives feedback about the body orientation from these three main
sensory systems and integrates this sensory feedback and subsequently generates a corrective,
stabilizing torque by selectively activating muscles. In normal condition, healthy subjects rely 70%
on somatosensory information and 20% Vestibular & 10% on Vision on firm surface but change to
60% vestibular information, 30% Vision & 10% somatosensory on unstable surface.

5. Contd…
• Achieving effective balance is a multi-system task. To keep up with
balance, an individual's focal point of mass should remain inside the
changing base of help. Postural control relies upon tactile data sources:
1. Somatosensory data from muscle and joint proprioceptors,
2. Cutaneous tangible data which recognizes surface qualities,
3. Vestibular data for head and trunk direction in space,
4. Gravity data from graviceptors within the storage compartment, and
5. Visual info.

7. CAUSES OF FALLS
• Age is a key risk factors for falls. Older people have the
highest risk of death or serious injury arising from a fall
and the risk increases with age. This risk level is in part
due to physical, sensory, and cognitive changes associated
with ageing[2], plus environments that are not adapted for
older persons.
• Gender. Both genders are at risk of falls. Older women
and younger children are more prone to serious injury
from falls. Globally, males consistently sustain higher
death rates and DALYs lost, possibly due to males having
higher levels of risk-taking behaviors and hazards within
occupations.
2. Tsujishita S, Nagamatsu M, Sanada K. Overlap of Physical, Cognitive, and Social Frailty Affects Ikigai in Community-

8. Falls Factors (from the UK Department of Work and Pensions
site)

9. OTHER RISK FACTORS INCLUDE:
• Occupations at raised heights or other hazardous working conditions.
• Alcohol or substance use.
• Socioeconomic factors eg. poverty, overcrowded housing, sole parenthood.
• Underlying medical conditions, examples include neurological (see eg falls and traumatic brain injury, falls and
dementia, orthostatic hypotension), cardiac vascular conditions (eg heart rhythm problem, persons recovering from
stroke, with weakness on one side)[3] or other disabling conditions [4]
• Medication side effects.
• Sedentary lifestyle.
• Poor mobility, cognition, and vision, particularly in those in aged care facilities.
• Unsafe environments, particularly for those with poor balance and limited vision (see Eyesight in the Elderly and
Ageing on the Special Senses).[1]
3 Heart org Falls can be a serious, poorly understood threat to people with heart disease Available:https://www.heart.org/en/news/2022/05/19/falls-can-be-a-serious-poorly-understood-
threat-to-people-with-heart-disease (accessed 3.11.2022)
4 Wu X, Guo J, Chen X, Han P, Huang L, Peng Y, Zhou X, Huang J, Wei C, Zheng Y, Zhang Z. Comparison of the relationship between cognitive function and future falls in Chinese
community-dwelling older adults with and without diabetes mellitus. Journal of the Formosan Medical Association. 2022 Nov 3.

10. INTRINSIC AND EXTRINSIC RISK FACTORS
• Intrinsic risk factors are traits of an individual that increase their risk of falling[5]; these are more
important amongst the oldest age group and can be related to neurosensory impairment, certain drugs,
or the presence of diseases associated with an increased risk of falling (e.g. Parkinson's, stroke,
osteoarthritis or diabetes[4]). The risk of having a fall or recurrent falls increases with the number of
associated intrinsic risk factors.
• Extrinsic causes are social and physical factors that relate to an external environment, unrelated to
disease or drug use; a slip on ice for example. Falls amongst people < 75 years are more likely to be
due to extrinsic factors than those aged 75 and over. If both intrinsic and extrinsic factors are present,
falls are classified as combined[6][7].
1.Wu X, Guo J, Chen X, Han P, Huang L, Peng Y, Zhou X, Huang J, Wei C, Zheng Y, Zhang Z. Comparison of the relationship between cognitive function and future falls in Chinese community-dwelling older adults with and without
diabetes mellitus. Journal of the Formosan Medical Association. 2022 Nov 3.
2.↑ Smith M. Medication & The Risk of Falls in the Older Person: The Facts. Produced on behalf of WAM Falls in Elderly Steering Group. 2004.
3.↑ Jump up to:6.0 6.1 6.2 6.3 Lord S, Sherrington C, Menz H, Close J. Falls in older people – Risk Factors and strategies for prevention. 2nd edition. Cambridge: Cambridge University Press, 2007.
4.↑ Formiga F, Soto A, Duaso E, Chivite D, Ruiz D, Perez-Castejon J. Letter to the Editor in: Bone; 40 (1); 242. Re: “Incidence and characteristics of falls leading to hip fracture in Iranian population” by Abolhassani et al. BONE
2006:39;408–13.
5.↑ Anami K, Murata S, Nakano H, Nonaka K, Iwase H, Shiraiwa K, Abiko T, Goda A, Horie J. The Association between Health Literacy and Gait Speed in Community-Dwelling Older Adults. InHealthcare 2020 Dec (Vol. 8, No. 4, p.
369). Multidisciplinary Digital Publishing Institute.

11. MANAGEMENT OF FALLS
The management of falls can be complicated. A combination of interventions, for example - medication
review, an exercise program, vitamin D supplementation, and home assessment are recommended. As the
causes of falls are often multiple, the treatment should be tailored to each patient based on the history and
physical examination.[9]
Clinical practice guidelines (CPGs) are clear that all older adult should be screened for fall risk at least
once per year. Balance impairment and gait and mobility limitations screening are an integral part of the
fall risk screening. [10]
It is becoming increasingly recognized that falls prevention requires a change in the person’s behavior
and should be approached from a psychological, and not just a physical perspective. This is becoming the
focus of health promotion[11] and it is such multidisciplinary intervention that has been proven to be of
most effect for fallers. [12][13].
1.Appeadu MK, Bordoni B. Falls and fall prevention in the elderly. InStatPearls [Internet] 2022 Feb 22. StatPearls Publishing.
Available:https://www.ncbi.nlm.nih.gov/books/NBK560761/ (accessed 8.11.2022)
2.↑ Avin KG, Hanke TA, Kirk-Sanchez N, McDonough CM, Shubert TE, Hardage J, Hartley G. Management of falls in community-dwelling older adults: clinical guidance statement from the
Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Physical therapy. 2015 Jun 1;95(6):815-
34.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4757637/ (accessed 4.11.2022)
3.↑ Benedetto V, Hill J, Harrison J. Cost effectiveness of fall prevention programmes for older adults. British Journal of Community Nursing. 2022 Nov 2;27(11):530-3.
4.↑ National Institute for Health and Clinical Excellence. 2004. CG21: Falls. Accessed from www.nice.org.uk

12. ROLE OF YOGA IN
PREVENTING FALL
• Yoga is a mind-body practice that typically involves
a combination of physical postures, breathing
exercises, and concentration/meditation.
• Yoga works on body as well as on mind. It aims at
improving neuromuscular coordination, the failure of
which is major cause in most falls. In addition, Yogic
practices have proven beneficial in many managing
psycho-physiological issues imparting an overall
improvement. They also help to reduce anxiety,
stress, pain and other types of distress making the
individual more alert and aware. This manifests as
better control on posture, gait and confidence thereby
reducing incidences of fall.
"ROLE OF YOGA IN FALL PREVENTION AMONG ELDERLY POPULATION : A SYSTEMATIC
REVIEW", International Journal of Emerging Technologies and Innovative Research (www.jetir.org), ISSN:2349-
5162, Vol.8, Issue 8, page no.a894-a907, August-2021,

13. LITERATURE REVIEW

14. Sno. Author
Name
Type of
study
Participants Yoga Intervention Duration
of practice
Contro
l group
Outcome measure Findings
1 Lisa Keay,
Devarsetty
Praveen,
Abdul Salam
et al. May
(2018)
Mixed
method
pilot
study
N= 50, age 60 years
and above, female-
29, male - 13, others
- not attended session
due to poor health,
house hold work)
Each yoga class included
warm-up 10 minutes, postures
- 50 minutes, Breathing g
exercises - 5 mins.,
Meditation on 5 mins.
I hour per
week for 3
months
Short physical performance battery, short
interview and short fall efficacy scales
international
Yoga was well accepted and resulted in
improved ability to rise from a chair, weight
loss, increased step length and reduced fear
of falling
2 Narjes nick et
al. (February
2016)
RCT n=40, Male - 17,
Women - 23, age 60-
74 years
Hath yoga, Pranaya ma- 10
mins. Warm up- 10 mins.
Asanas - 30 mins. Relaxation
- 10 mins
duration- 1
hour twice
a week for
8 weeks
Modified Falls efficacy scale, Demographic
data questionnaires and berg balance scale
Yoga is a potential intervention to reduce
fear of falling and improve balance in older
adults
3 Albertas
Skurvydas, et
al. (September
2020)
RCT n=33, age 60- 79
years, female30,
male - 3
Warmup 15 mins. Asanas- 45
mins. Himalayan kriya
Breathing exercises- 25 mins.,
Relaxation in shavasana 15
mins.
Duration -
90 mins.
Twice a
week for 10
weeks
Brunel Mood Scale, Heart rate Variability,
Perceived stress scale, computerized
Automate d Neuropsychological
Assessment Metrics version 4, Dynamic
Parameter Analyzer, postural sway activity
was measured by a posturography method
using single piezoelectric force plate. serum
concentration of free BDNF(enzyme linked
immunoessay)
yoga is a potential intervention to reduce
fear of falling and improve balance in older
adults
4 Krishna Ketan
Patel, et al.
(April 2019)
RCT n=40(Male – 21)
Female - 17), age -
60- 75 years,
warm up- 10 mins., asanas -
25-30 mins., Pranayama and
relaxation
5 times in a
week for
four weeks
Clinical Test of Sensory Interaction in
Balance (CTSIBM), Timed Up and GO test
(TUG) was recorded before and after the
intervention
The study conducted concludes that
yogasanas are effective in improving
balance in elderly individuals at the end of
four weeks compared to control group.
Thus, it can be used clinically to improve
balance in geriatric population.
5 Zettergren, et
al. June 2011
Pilot
Study
n= 16 (females) age-
65 and above
kripalu yoga Pranayama and
Body awareness 10 mins.,
warm up activities 10 mins.,
asanas supine and standing
position 50 mins., shavasana
and meditation in 10 mins.
duration=8
0 minutes
twice a
week for
8weeks
Postural control (Berg Balance Scale),
mobility (time to rise from the floor to
standing, Time Up to Go), Gait (usual and
fast speed), balance confidence (Activities -
Specific Balance Scale)
This study concluded that postural control
and gait has improved in Yoga group.

15. • The control group in all the studies received no
intervention or wait list.
• Yoga interventions included Warm up , Asanas
(Utkatasana, Vriksasana, Trikonasana, ardh
chandrasana, Virbhadrasana 1,2,3,
UttanaPadasana, Chakra Padasana,
Sanchalanasana , Lurhakanasana, Shava
Udharkarssanasana, Naukasana,
Namaskarasana, Vyagrasana, Ushtrasana, Hasta
Uttanasana, Tadasana, Tiryaka Tadasana,
Tiryaka kati chakrasana, Dhruta Utkatasana,
Dwikonasana, Bhujangasana, Ardha
shalabasana, Eka Pada Pranamasana, Eka
padasana, Sarvangasana, pavanmuktasana,
shavasana).

16. OUTCOME MEASUREMENT TOOLS
• Fear was measured in two studies by using Modified Fall Efficacy Scale and
Short Fall Efficacy Scale- International.
• Balance was measured in five studies by using Berg Balance Scale, Short
Physical Performance Battery, Clinical Test of Sensory Interaction in Balance,
and a posturography method using a single piezoelectric force plate.
• Gait was measured by Short Physical Performance Battery, usual and fast
speed.
• Mobility was measured in three studies by Short Physical Performance
Battery, Time to rise from the floor to standing, Time Up to Go Test, Dynamic
Analyzer

17. 1. Keay L, Praveen D, Salam A, et al. A mixed methods evaluation of yoga as a fall prevention strategy for
older people in India. Pilot Feasibility Stud. 2018;4(1):1-7. doi:10.1186/s40814-018-0264-x
2. Nick N, Petramfar P, Ghodsbin F, Keshavarzi S, Jahanbin I. The Effect of Yoga on Balance and Fear of
Falling in Older Adults. PM R. 2016;8(2):145-151. doi:10.1016/j.pmrj.2015.06.442
3. Čekanauskaitė A, Skurvydas A, Žlibinaitė L, Mickevičienė D, Kilikevičienė S, Solianik R. A 10-week yoga
practice has no effect on cognition, but improves balance and motor learning by attenuating brain-derived
neurotrophic factor levels in older adults. Exp Gerontol. 2020;138(May). doi:10.1016/j.exger.2020.110998
4. Patel KK, Deshmukh M, Palekar T. Effect of Yoga on Balance in Geriatric Population. Int J Sci Res Sci
Technol. 2019;(April):595-605. doi:10.32628/ijsrst11962130
5. Zettergren KK, Lubeski JM, Viverito JM. Effects of a Yoga Program on Postural Control, Mobility, and
Gait Speed in Community-Living Older Adults: A Pilot Study. J Geriatr Phys Ther. 2011;34(2):88-94.
doi:10.1519/JPT.0b013e31820aab53

18. RESEARCH EVIDENCES
• Yoga intervention was associated with significant improvement in fall prevention
including balance, gait, mobility, fear of fall, postural control and gait speed was
reported. In the above mentioned studies, some are good quality studies and some
are moderate quality studies.
• Studies included 4- 10 weeks yoga program. Fear of falling was measured by two
studies and significant improvement was reported. Study by Keay et al. measured
acceptability and feasibility of yoga as fall prevention have shown improvement in
short fall efficacy scale- international, in sit and stand test, 4- m walk and took less
steps to walk 4- m distance and there was no change in performance on the test of
standing balance

19. CONCLUSION AND SCOPE FOR FUTURE STUDY
• Yoga is most effective intervention for tackling with the problem of
risk of fall in elderly population.
• If the study can be repeated with larger sample, longer duration and
proper blinding methods, it can be proved statistically significant
too.
• We should fully explore the potential size of the impact on balance
from a higher dose yoga-based intervention.