Systematic Review: Exercise Therapy Program To Reduce Incidence Of Falls Among Elderly In Residential Aged Care Setting

Visible Changes

Give a systematic review on to reduce the incidence of falls among elderly living in residential aged care setting by exercise therapy program”.
 

Change Record

Comparing to the younger generation following changes can be seen older generation in term of physiologically (Thor et al., 2011)

System	Older vs. younger Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	Importance
Nervous system	There is higher occurrence of cognitive injury, their ability to assess pain becomes weaker	May have become worst because of pain medications. This can be analyzed by using behavioral scale
Cardiovascular system	Frequency if heart diseases increases	Number of consequences may arises because of treatment supplied to  hypertension
Pulmonary system	Sleep apnea increases in incidents	Treatment of oxygen after operation; more than required interval between doses
Hepatic system	Metabolism of drugs decreases	Reduction in doses

Skin of older people becomes more wrinkled with visible lines, it elasticity also decline with the pace of increment in the age. Due to the reduction in hair pigments cells hairs becomes thin and grey. When old aged people reach in their 80’s the normal rate of height fall is 2 inches. Changes occur in hearing ability of older people, they start listening less clear voice from the year of 55. A very common change occurred in every old person is their eye sight, its tends to reduce when they get older (2015)

Older adults face serious fall because of unstable balance are considered to be one of the serious clinical problems. These falls have become very conmen in elderly aged people further these falls leads elderly aged people toward mortality and morbidity. Even these falls are the reasons of placing them in immobile and premature homes of nursing. Kellogg (Gibson, 1987) defined elderly fall as absence of consciousness, not intentionally moving toward ground. Many researchers have utilized this or similar definition in defining the elderly aged falls in their study.

These falls are devastating in nature because these provide injuries to individuals and also bother their support network. Martin and his group (2013) mentions in his study that these falls can be reduced up to high extent with proper treatment of physiotherapy. The problem have become so widened that at 65 years old people falls at least once or more often in a single year. These falls brings reduction in confidence, increment in injuries and also lowers the rate of day today activities carried by their own self for self purpose. If these falls are not reduced for present population due to proper measure taken than the number of falls will get increase due to the global rate of population moving toward older age. Likewise in Australia 65 aged people were expected to increase from 13 % that is approximately three million people till the end of 2010 and 24 % which is nearly nine million people are expected to reach old age by 2050 (Begg et al., 2008). This clearly means that more old aged people in near future means more rate of their falls; when there will be more injuries which may lead them to mortality.

Background

In the usual life of human, they are supposed to perform certain activities in order to meet their requirements of daily desires. These falls usually occur when these is abnormal mismatch between the individual physiology and support from environmental material. There are number of body structure needed for the position of upright. In order to have proper upright than balanced combination of body structure and functions are required. Older people needs many things together at adequate if they want to reduce the number of falls. They have to be understand the environmental challenges where they are moving aren’t that place is slippery or uneven to walk properly. They are needed to understand the insight of their body parts. They must have mental as well as physical awareness to understand and take action against the possible fall. They are also expected to have strength required to move on against the direction of fall. The combination of all these things together can prevent falls among older people.

1. What is the impact of fall on old aged people?
2. What risk it involves in terms of injuries and confidence?
3. What are the provisions can be taken in order to reduce these falling rates?
4. What are the recommended exercises programs carried to prevent these falls at home?

This study requires to include the manual with automated search because the nature of the study. The basic ground for any research or study is required and relevant information needed right from the beginning of the study till the end of study. Information for study has been taken from books because it gives general to specific information. Journals are also included in the study because it plays an important role of source in providing specific and current information. Useful and relevant information have been taken from internet in addition because many articles are published online, statistics of old age people included in study are taken with help of internet. So in order to provide the complete but relevant information in study both searches have been taken into consideration.

Exton smith in 1977 found out that woman fall rate was more as compare to the man fall rate. Further  (Campbell et al., 1981) results exposed from 533 subjects that were above 65 had falling experience of 33% as compare to its last year experience of fall. In current years of study it has been observed from the old age study that there has been increase in the fall rate of old aged people. Lord concludes in his study that 39 % woman out of 241 had two or one fall in a single year (Lord et al., 1993)

There were about 50% of falls used to occur inside of homes or nearby home. Within the house falls used to occur in bedroom, from stairs, through stools and even in living rooms (Luukinen et al., 1995). The findings about location of fall reveals that location of has strong connection with the majority of actions took place either outside or inside. Study conducted on the time of fall shows that most of the falls used to occur on day and afternoon time where as only 20% of fall used to occur at night timings (Campbell et al., 1990)

Research Questions

Consequences concerning to fall are quite severe because old people are not so strong to deal or recover from the injuries easily as compare to the younger people. People having age above 65 years are hospitalized because they casually fall and this accounts almost 4 % admission rate of hospitals (Baker & Harvey, 1985). In some of the serious cases theses falls leads people towards lifelong immobility due to hip fractions, this fraction also leads to death in often more sever situation (Marottoli et al., 1992)

• Daily basis exercise
• Altering the environmental objects in order prevent falls
• Proper selection of footwear in order suit the speed and prevent slips
• Carrying devices along with one self to which provides assistance in walk
• Proper prescriptions of medicines in order to reduce falls
• Continues up to date file maintained with physiotherapist (Lord et al., 2001)

 A study on 17 hospitals considering 29,972 as participants reveals that proper intake of vitamin D brings major reduction in number of falls occurring in old age. Proper number of facilities in the environment of hospitals, exercising provisions meant at providing improvement in physique and bones of older people. But this provision did not provided accurate result of improvement as extent to the amount of proper exercise carried varied from hospital to hospital. On the other hand number of interventions carried together provided sufficient improvement in the number falls rate of old aged people. Therefore though it was evidenced that interventions together will improve the fall rate if proper facilities are provided in hospitals however but however it was inconclusive as it still did not covered the whole risk of falling (Cameron et al., 2012).

When we follow many interventions at a time it becomes very difficult to verify or determine the results. Even the impact cannot be measured properly. Therapy exercise program followed as a single intervention can be easily measured for better and accurate results. These results can also leads to proper remedies which can heal the causes of fall in old aged people.

It has been observed that people who remain active in their schedule experience lesser fall as compare to the people who are not active in their schedule (Haseech et al., 2008). Nonetheless, there are no such evidences available which can prove that activeness can be the major remedy, when it comes to reduce number of older aged people falls. So encouraging older people to remain active in their schedule will not heal the problem of severe falls. On other hand it can be highly possible that people having no exposure of physical activities may lead them to fall because they find it risky to get involved as they become physically weak due to none of  any physical activity.  

Search Strategy

Several number of analysis have concluded in their studies that exercises includes the challenges of balance are more likely to prevent falls with comparison of type of exercises which do not hold balancing challenge (Sherington et al., 2008). Training of balancing provides 19 times much effective results in preventing the number of falls as compare to the exercise without this training. Extreme level of training includes the structuring of balance in which allowing older aged people to stand for longer hours. For doing so participants are directed to follow these steps:

• They are supposed to stand with closer feet or have stand on a single leg
• They are not allowed to use their hand in between to support their balance
• They have to control their movement by concentrating

Huge success in improvement can be observed when training of balance is combined with other few exercises but with no inclusion of walking. This combination have provided 42% of improvement in the fall rate of old aged people which states that 42% number of falls were reduced. Programs having exercises and walk together also reduced the number of falls but programs having walking and balancing together did not provided that effective results. 

The rationale behind exclusion of walking from other exercising approaches for prevention of fall among old age people is because:

1. While walking people become more expose to the risk of falling on ground
2. Gesture of walk leads away the level of high balance or
3. It was also interestingly found that walking had correlation with high risk among residents

Even though walking did not provided any purposeful benefits in preventing the falls for older people but on the other side it has other benefits for same age group (Nelson et al., 2007). Walking would have been included as one of the way of preventing falls among elder people but due its requirement of huge time taken in providing balance it is excluded.  Programs of exercising aims at providing the prevention if in any case is including walk than participants are well assessed before implementing as it involves risk of balancing and participants may face falls.

Impact of exercise is observed very less among old aged people who tried to reduce the number of falls with help of exercise when reached the level of higher level risk in falls. Therefore the impact of exercise works more effectively when is less number of falls per year that is 2 falls per year.

Meta analysis study conducted to determine the significant difference of care took among personal residence and nursing homes to reach the conclusion that which one was more effective in providing better prevention in the number of falls. The study revealed that the exercises followed at the personal residence did not provide any measurable impact on the prevention of falls. On the other hand it was seen that older aged people who were taken care and were provided with exercises from time to time their rate of fall per year was reduced (Cathrene et al., 2008).

Findings from Literature Reviews

The previous studies on the schedule of the exercises followed per week and required time to make more effective result reveals that

• Two hours per week
• For a six months
• Regular exercise is highly beneficial as compare to occasionally

In the testing of Meta analysis study, huge impact of exercise was observed which was included almost higher than 50 hours of exercising. This resulted into 20% of improvement in preventing the number of falls per year. The testing of exercising considering different hours turn our out to be different around 22% (Sherington et al., 2008). 

The total time taken in testing was a combination of following the exercising partially at home and with group, so this means that once a week outside of home with group otherwise rest of the days performing exercise at home (Barnett et al., 2003). Exercising used to be carried out in smaller portions either performing the exercise twice a week for one hour sometimes for three days in week, even occasionally these 60 minutes of exercise used to be replaced with 40 minutes.

This was also observed that when exercise sessions were not in continues format the benefit occurring out of it used to be lost (Nelson et al., 2007). So programs aimed at reducing the number of falls had to remain continue in process in order to be beneficial. All participants following the programs of exercise have to be encouraged to remain in touch with exercise.

Some of the Meta analysis study proves that there is limited scope of preventing falls within residential area on the other some Meta analysis turns out be highly positive in results. The study which proves exercise is beneficial within homes suggest exercise can prevent falls, programs that are including continues schedule of exercise with training of balance are highly effective in reducing the number of falls.

 Older age people who have completed their 85 years of life in some cases even more than that or they are having limitations in performing certain movements they may face more risk of falling. Exercising aimed at reducing the number of falls must not prescribed to people for whom it may become reason to fall, therefore before prescribing the number of exercises to people their physical ability to carry out that exercise needed to be analyzed at primary priority. There is evidence which suggest that number of exercises seems to be good and relevant to aged people is successful at minimizing number of falls (Sherington et al., 2008).

There had been number of falls observed in New Zealand which became the cause of many older people mortality. In order to reduce the research group specifically took this issues into consideration and focused on its solution. Therefore they launched program of exercises at home to prevent usual falls among old people. The program was named as Otago, this aimed at providing strength to the older muscles and training them to learn balance at their home place through a well trained instructor

Preventions through Interventions

In prevention of falls among old people Otago program considered the strength of leg muscle and balance highly important. Stability can only be achieved through this. People belonging from the age group of 90s can also reduce the number of falls with suitable home based exercises.

Exercises must be designed or scheduled in way that it must be able to carry on the benefits it is holding within. This can be achieved when exercises are slow in movements in initial times. Old aged people need motivation in this process, instructor have to remain in touch with these people sometimes through personal visits or sometimes asking the improvements through telephonic conversation. Family also play vital role by supporting and motivating the old people to remain continue in exercises.

The programs also required measures to be monitored for desired success. There must be proper record of falls each month occurring by maintain the calendar. Reasons of falling and place where fall is occurred must be verified. A close check dairy should be maintained which bears the record of conformity with exercise instructor. In between tests must be taken to verify the improvement this not only will motivate older age people to be continued with exercises but also makes sure the level of improvements. 

This program has complete package as it includes activities focusing on the strength of leg muscles, balancing and some cases if suggesting walk than prescribing proper measures to be taken. These programs puts light on the assessment of achievement in that they verify stamina of ankle cuff, safety in performing each exercise. In this programs increment is number of exercise is made on slow speed. Frequency of these programs also verifies the comfort zone by keeping rest days in between for older people. 

Safety of older people must be scrutinized at priority. The older people should not be allowed to hold any materialistic thing which may have feature of movement. Older people may be are in need of having something to hold while performing exercise than they should be suggested to hold something sold material or things such as bench or table but usage of these material is again restricted if it is not prescribed by the instructor. Older people are suggested to cal their doctors if they feel chest hurting and dumpiness of breath (Li et al., 2016) . 

In olden studies subjects or selected participants were asked to provide the number of falls they had in past period but this did not provided the accurate result as they used to forget the accurate number of falls (Cummings et al., 1988). But in recent studies old aged people were asked to fill the questionnaires twice in between months or weeks to verify the exact number of fall.  

Exercising Interventions in Hospitals

It is very important to have participants or respondents who represents the entire population so in this study man or woman having reached the age of 60 (James et al., 2009), starting from sixty of age because generally from this age people start complaining about bone issues or other health related issues. Therefore participant belonging from age 60 or above are considered to be as old. So people not belonging to this age group are excluded from the study. These studies have also concentrated on primary data derived from the sample selected from the targeted population. Interviews of physiotherapist also has been taken in order to  understand what measure exercises are needed and what nutrients are required to be taken in order to avoid such falls.

The chosen language in reviewing the articles or books fir this study was English. Almost every country study published in English language is taken into consideration. Records of trauma are not relating to falls in this study.

Two assessors separately checked the quality of studies included. Controlled studies and RCTs were assess by using Cochrane Collaboration risk bias tool (Deeks et al., 2011), uncontrolled studies were assessed through two check lists; however full details can be seen below in table:

Randomized controlled trails all either scored as Yes (+)/ No (-)/ Unclear
Sequence generation	Was allocation of the sequence properly generated?
Allocation secretion	Was the allocation properly kept as a secret?
Blinding	Was knowledge of the allocation properly kept secret from the result assessors?
Incomplete outcome data	Was each outcome adequately addressed/
Selective result reporting	Are the reports of this study free of advices of selective outcome reporting?
Other biases	Was the study away from the claims that can put this at high risk of bias?
Controlled before after studies all scored as Yes (+)/ No (-)/ Unclear
Selection bias	Are individual included in the study were presenting targeted population?
Blinding	Was knowledge of the intervention were concealed from the outcome assessors?
Detection bias	Was outcome measure and were reported in standardized way
Incomplete data	Was data adequately addressing each of the outcomes?
Selective outcome data	Report were free of outcome suggestions or not
Other sources of biases	Was the study free from risk of biases?

Two assessors reviewed separately the titles and abstract having proper citations recognized through search engines, applied and criteria of selection was probably relevant study papers and also extorted the data among the selected studies by applying the standardized form which was well piloted before use. Disagreements occurring were sorted out with assistance of third reviewer. We extracted the information on basis of type of study design, aims of study, selections of participants, their settings, intervention (having details about provider, time and intensity) and results.

Longitudinal studies were analyzed throughout the literature and few were Meta analysis. From longitudinal study results show that analyzing and evaluating the impact of interventions of exercises at home had evidenced impact on older people. Meta analysis of longitudinal studies also proved the same. Studies were classified into group of different types of interventions used in studies for healing the fall of older people.

Chapter	Topic	%	Words	Months
1	Introduction	5	3500	3
2	Literature review	30	21000	6
3	Methodology	20	14000	4
4	Data analysis	25	17500	5
5	Conclusion and implication	20	14000	6
Total		100	70,000	24
(Phillip & Pough, 1987)

3. Conclusion

Fall in old age people have become very common these days. Number of falls is ever increasing may be because of no proper implementation of studies conducted in this era. Studies show that injuries occurring from falls among old people lead to them to face mortality. Sometimes it brings lifelong immobility which again is half death for any normal human being. It has been widely investigated that number of older people will increase globally in coming years. As compare to man there is relatively more rate of fall in older women. When they fall they do not have that strength to put all adequate requirements from their weak body and utilize this strength in keeping them safe from fall.

Specific versus Multi Interventions

There are no problems which do not serve solutions, every problem bring hints of solution with them. In this case to prevent these falls in residence, proper and well trained instructor that can be hired who can give time to time required instructions about exercise. Along with these instructions the weak body of old people must be scrutinize well than tailored exercise suitable to their physiques must be provided to them.

These old aged people not only need support from instructor for remaining fit to fights falls but they also need motivation from family and friends. It also been observed that old people not only falls outside the home but also inside of home so home environment also have to scrutinize and well settled in order protract these delicate bodies from falling. Not only homes but when they are admitted in hospital for any reason than their also regular exercised had to be continued in order to sustain its benefits.  These exercises are needed to be properly assessed and well co ordinate with stamina of body. As it should not be the case that while exercising they become more expose to risk of other injuries because exercise are meant at benefiting the health not at providing the hazardous to life

The research gaps in this area can be meant at investigating the interventions such as dance, bowls or golf games, study carried on these interventions may bring beneficial impact on old age people. Numbers of different exercises are available but there is no comparative study discovered yet which can prove the difference along with its importance.

The further study can also put light on concentration paid on mid life exercise whether these can prevent old age falls. Despite of observing the impact of trials on people on 4 to 5 times it can increase to 7 to 9 trials. The comparative benefits I still not analyzed by keeping single intervention versus multi interventions.  

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