Running head: ELDERLY BALANCE AND FALL RISK

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An integrative literature review of interventions to reduce fall risk in elderly individuals who
participate in balance exercise programs.
Julia R. Bland
University of Central Florida

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Abstract

Objective: To evaluate the available evidence aimed at defining the measures necessary to
improve balance and reduce fall risk in the elderly population and to evaluate the effects of
balance exercise programs on balance measures, fall incidence and fall risk in communitydwelling elderly adults.
Background: Thirty-three percent of elderly people fall in the United States per year Every 15
seconds, an elderly person visits the emergency department following a fall and every 30
minutes, an elderly person will die following a fall.
Design: An integrated literature review
Method: Searches of professional databases including CINAHL, OVID, MEDLINE, and
Cochrane Library included the span of 2005 to 2014. A descriptive synopsis of the information
followed a critical appraisal of the articles and synthesis of the content contained therein.
Results: Participants had a mean age of 75.6 years and included low risk 25.6%, moderate risk
25.6%, and marked risk 48.7% for falls. The cumulative 1-year fall incidence was 25.2% in the
intervention group and 27.6% in the control group (hazard ratio 0.90; 95% confidence interval,
0.66 -1.23). The intervention group improved more favorably.
Conclusion: Fall prevention programs that included exercise interventions improved balance,
functional performance, and reduced fall risk among community-dwelling elderly individuals
compared with control groups.
Relevance to clinical practice: Retaining muscle strength and flexibility of the lower
extremities is fundamental to reducing falls among the elderly population. Despite the variations
of methods included in this review, any method to accomplish this task can only provide benefit
to those at risk or have future risk of sustaining a fall and possible catastrophic injury.

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Significance
Every 15 seconds, an elderly person visits the emergency department following a fall.
This equates to 2.4 million elderly people annually. Every 30 minutes, an elderly person will die
following a fall. This equates to 22,000 elderly people annually (CDC, 2013: NCOA, 2012). It is
estimated that more than on 33% of elderly individuals fall in the United States per year (CDC,
2013; Trombetti et al., 2011; Beling et al., 2009; Means et al., 2005). The incidence of falls
increases as a person ages and approximately 50% of those who do fall will fall again (Trombetti
et el. 20011). The economic impact of falls among the elderly is currently around $36 billion
dollars annually. With the unprecedented population boom of aging adults in America now at a
record rate, the economic impact of this boom is projected to reach $60 billion by the year 2020
(NCOA, 2014; CDC, 2013).
Elderly individuals become increasing prone to falls as risk factors for falls develop often
as a result of physical decline (Beling et al., 2009),. Some of these diverse issues include
reduced leg-muscle strength, shortened gait, reduced vision and cognitive decline; all resulting in
the principal impairment which is loss of balance (Volger et al., 2009). According to Beling et
al. (2009), elderly individuals with impaired balance have a three-time greater risk for falls
compared to those who have no balance impairment. Comorbidities and external factors such as
postural hypotension, neurological and cardiovascular disease, polypharmacy and medications
having cardiovascular or psychotropic effects are associated with an increased fall risk (Beling et
al., 2009; Volger et al., 2009; Means et al., 2005).
Falls can result in injuries whose outcomes may include long-term disability, loss of
independence, extended care facility placement and even death (Singh et al., 2011). As a result,
the short and long-term consequences of falls can reduce the quality of life in the elderly (CDC,

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2013; Sakamoto et al., 2013). Most adults who fall develop a fear of falling even if there was no
injury sustained. Fear of having a secondary fall limits activities which results in the loss of
physical fitness and increased risk of falling. These events can lead to depression, social isolation
and cognitive decline (NCOA, 2014; CDC, 2013; Trombetti et al., 2011)
Exercise prevents the onset of multiple pathologies and functional capacity decline.
Moderate physical activities and exercise also lowers risk of falls and fall-related injuries that
occur in older age (Lee et al. 2013; Carpenter et al., 2010). Routine physical activity is essential
to good health and maintaining independence. Individuals who participate in regular exercise
have been shown to have improved strength and flexibility, are more physically mobile and less
likely to fall (Gobbo et al., 2014; Lee et al., 2013; Li et al., 2005).
Balance programs can be accomplished by modifying established modes of exercise that
improve strength while enhancing flexibility and overall sense of body awareness in the
environment (Gobbo et al., 2014). A number of quantifiable indicators of balance and mobility
are associated with functional performance; they include activity level, muscle strength, and joint
flexibility. Participation in an exercise program to improve functional performance, balance and
mobility may prevent falls by affecting some of these clinical and functional components (Beling
et al., 2009).
The purpose of this integrative review is to evaluate the available evidence aimed at
defining the measures necessary to improve balance and reduce fall risk in the elderly population
and to evaluate the effects of balance exercise programs on balance measures, fall incidence and
fall risk in community dwelling elderly adults.
Method
This limited integrated review followed a systematic search of several professional databases
including CINAHL, OVID, MEDLINE, and Cochrane. Key search terms included the following:

ELDERLY BALANCE AND FALL RISK

Population: Elderly, Elderly People, Older Adults

Intervention: Balance Therapy, Balance Training, Exercise

Outcome: Balance Problems, Falls, Fall Risk, Fall Prevention

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Inclusion criteria were those studies whose participants were older than 65 years of age.
Participants must have been ambulatory and preferably community-dwelling individuals;
meaning those living in and environment that did not require continuous monitoring or care.
Studies had to involve the evaluation of a balance exercise program on balance improvement,
reduced fall occurrence, or reduction in fall risk. Studies had to include either fall rate or
improved balance scores among participants during the study period. Exclusion criteria included
studies whose participants were nonambulatory individuals, nursing home residents or
hospitalized elderly individuals. Studies were excluded that did not include some form of balance
measurement scale or neurological method to determine balance. Studies were excluded when
evaluation of the cognition of participants could not be determined. Article quality and level of
evidence were determined using criteria published by Melnyk and Finout-Overholt (2011).
Results
Utilizing MEDLINE, CINAHL and Cochrane databases, 26 articles of interest were
found that addressed the assessment of exercise interventions and reduction of falls in the elderly
population. After reviewing the articles, 16 were eliminated. Of these 16 articles, six where not
randomized control trials, ten of the trials were excluded due to poorly described research
processes within the abstract, non-blinding or the appearance of bias in the results. Following
further review, ten articles were considered relevant and retrieved as full text. Of these ten
articles two were systematic reviews and eight were randomized control trials.

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It was determined this limited integrative review, though narrow in its scope, would
include a range of interventions employing balance exercise as a practice method to reduce falls.
This method was to establish whether the evidence was significant despite the mode of
intervention. This narrative analysis will include practicality, relevance and significance of the
intervention utilized. Individual characteristics of the articles such as design, level of evidence,
sample size, description of the intervention and results are outlined in Table 1. The articles are
organized alphabetically and categorized into two clusters based on the way the intervention is
applied which were Group Dynamics and Tailored Individualization.
Group Dynamics
This group of studies included three RCT’s, one systematic review, and one metaanalysis which utilized interventions based on the dynamic of groups as a supportive context that
rewards performance and cooperation. Beling et al. (2009), Li et al. (2005), and Trombetti et al.
(2011) RCT’s investigated whether exercise instruction focusing on balance, mobility and
strength in a group setting would reduce fall rate. These studies significantly improved balance
measures ranging from10-20% post intervention and significantly reduced the incidence of falls
ranging from 25% - 40%.
Of the meta-analysis and systematic review included in the Group Dynamics both
Gillespie et al. (2013) and Gobbo et al. (2014) included studies that studied exercise effects in a
group setting. The Gillespie et al. (2013) review included 22 studies that studied group methods
and reported a 30% pooled reduction in fall rate and a 25% pooled reduced fall risk with the
group interventions. Of the six studies included in the Gobbo et al. (2014) review, reported
individual improvements in balance parameters ranging from 5%-30% assuming fall risk
reduction would be a consequence of the activities described in this study.

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Tailored Individualization
Individualized instruction incorporates practices of teaching which identify the
individuality of each learner and offers class guidance, and support services to develop skills
based on the individual’s unique ability. This approach can be seen in the methods incorporated
in the studies conducted by Lee et al. (2013), Means et al. (2005) and Volger et al. (2009). These
three RCT’s included individualized instruction using teaching methods to connect with the
individual’s learning methods. The results of the three RCT’s demonstrated appreciable
improvement in balance measures ranging from12% - 19%, significantly reduced fall rates
ranging from 2.4% - 54% and reduced fall risk ranging from 10% - 40%.
Tailored individualization can also refer to developing strategies that individuals can do
in their own home and on their own schedule. The remaining two studies performed by
Sakamoto et al. (2014) and Singh et al. (2011) utilized individualized instructional methods of
exercise in concert with an individual’s learning style. Both studies relied on individual’s
participation and motivation to perform routines at home. Sakamoto et al. (2014) used body
poses to improve balance and core strength whereas Singh et al. (2011) utilized technology to
obtain the same goal. . The results of the two RCT’s demonstrated significantly improved
balance measures ranging from 23.6% - 44.4%, and significantly reduced fall rates ranging from
6.5% - 54% and reduced fall risk ranging from 8.2% - 43.7%.
Limitations
There are several limitations noted with these studies. Three studies had smaller sample
sizes (<100 subjects) which call validity into question and invite bias. There were considerable
variables between studies. Each study utilized a different mode of exercise intervention outlined
in Table 1. The balance measures varied also with two studies using the Berg Balance Test,

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three using the Physiological Profile Assessment (PPA) to measure fall risk and two measuring
degrees of sway. These variables place limits on the generalizability of the results. The follow-up
times ranged from six weeks to 52 weeks. The majority of the interventions were applicable in
most patient settings though there needs to be a concise method for determining balance and a
method to keep individuals motivated in performing specific interventions so that gains are not
lost over time.
Conclusion
Fall prevention programs that included exercise interventions improved balance,
functional performance, and reduced fall risk among community-dwelling elderly individuals
compared with control groups. There were fewer falls in the intervention groups were fall rates
were measured. Fall incidence may have declined concurrently in the intervention groups due to
an amplified awareness of fall risk established during evaluations, instruction, and
recommendations. The exercise programs did produce a lower risk of falling among elderly
individuals with various fall risk statuses. Exercise programs must be personalized to elderly
individuals with diverse functional levels or fall risk.
Recommendations for Practice
Practice: The aging elderly population is diverse in cognitive and physical abilities making it
challenging to develop strategies for fall risk reduction that would universally meet individual
needs. The one common thread throughout the studies is that retaining muscle strength and
flexibility of the lower extremities is fundamental to reducing falls among the elderly population.
Incorporating balance exercise instruction or having balance exercise programs available to the
elderly population is integral as a practice measure in reducing fall rate and fall risk in this
vulnerable population.

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Education: Campaigns to educate both the medical community as well as the public is vital to
having successful methods of addressing the crisis facing elderly individuals in the community.
With falls occurring with such high frequency (every 15 seconds) there is obviously specific
knowledge gaps that must be addressed to reduce the morbidity and mortality of falls among the
elderly. Specific educational programs for medical professionals as well as campaigns to educate
the public should be widely available.
Health Policy: Hospitals, health clinics, community centers and any facility that deals with the
health and wellness of the elderly must recognize that uniform policies directed at maintaining
the fitness levels of active older adults and improving the fitness levels of less active older adults
is necessary in order to improve balance, reduce fall rates and reduce fall risk.
Future Research: Investigations attempting to quantify the effects of exercise-based
interventions on balance, mobility, and falls have employed quite a range of approaches that
have generated heterogeneous outcomes. The variability of clinical approaches makes organizing
a collective interpretation of effects problematic. Despite the variations of methods included in
this review, any method to accomplish this task can only provide benefits to those at risk or have
future risk of sustaining a fall and possible catastrophic injury.

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