Tai chi 'prevents falls in the elderly'

Behind the Headlines

Friday January 14 2011

The elderly are being told to “take up tai chi to prevent falls”, reported The Daily Telegraph. It added that updated guidelines for preventing falls in the elderly recommend tai chi as one example of an exercise for “balance, gait and strength training”.

This news story is based on an updated guideline, released by the American and British Geriatrics societies, which suggests ways of preventing falls in the elderly. In light of the evidence available, one of the strategies recommended was participation in exercise programmes that target balance, gait and strength training, which all reduce the risk of falls. Tai chi was highlighted as a type of exercise that studies showed could lower the risk of falling in the elderly.

The guideline also highlights other factors that may increase the risk of falling in the elderly. It recommends that doctors and other health professionals assess heart, neurological and foot health, medication and an individual’s living environment alongside their mobility, strength and balance to try to provide treatments or practical ways to limit these risks.

Elderly people who are unused to exercise should consult with their doctor about appropriate exercise programmes for them to start with.

 

Where did the story come from?

The study was carried out by researchers from the American and British Geriatrics societies. The full guidelines were published on the American Geriatrics Society website and a special article summarising the guidelines was published in the Journal of the American Geriatrics Society.

The BBC and The Daily Telegraph lead with the recommendation to take up tai chi. The BBC also covered some of the new recommendations contained in this guideline.

 

What kind of research was this?

These guidelines were based on a review of the evidence of methods to prevent falls in the elderly. The aim of the review was to suggest prevention strategies that could be recommended to elderly patients by doctors. This was an update on a previous guideline that was published in 2001. The new guideline was written by a panel of experts including physical therapists, pharmacists, nurses and experts in orthopaedics, homecare, care of the elderly and emergency medicine.

The panel assessed new randomised controlled trials (RCTs), systematic reviews and cohort studies published since the old guidelines. Their findings were used to determine a clinical strategy for the clinical treatment of older people who have had recurring falls, difficulty walking or have been injured following a fall.

Some of the treatments had sufficient evidence to be termed “evidence based”. However, others had ambiguous or conflicting evidence. In these cases, the multidisciplinary panel made recommendations based on consensus after discussion.

 

What did the research involve?

The researchers looked at studies that had been published and recorded on various medical research and science databases. They were particularly interested in studies that looked at non-drug ways to prevent falls outside of hospitals. The researchers excluded research that had investigated bone health, hip protectors or falls in hospital that may also be important in fall and injury prevention.

As with most evidence-based guidelines, the members of the panel also graded the quality of the evidence (how well the studies had been carried out) and how each prevention strategy benefited patients.

 

What were the basic results?

The panel made the recommendation that older adults that are under the care of a health professional (or their caregivers) should be asked at least once a year about falls, frequency of falls and difficulties in gait or balance. The group recommend that elderly people who have a history of falls, or are shown to have abnormalities in gait or unsteadiness, should be investigated by a health team for possible risks of falling. These risks include the condition of feet and footwear, mobility and muscle strength, heart function, vision, neurological impairments, medications, low blood pressure and environmental hazards.

They should also assess how active and able individuals are at completing daily living tasks, and make an assessment of the safety of their home and how they perceive their functional ability to be and their fear related to falling.

The researchers say that all interventions to prevent falls should have an exercise component that includes balance, gait and strength training such as tai chi or physical therapy, in group programmes or individual programmes at home. They particularly highlight tai chi because of new evidence showing that this type of exercise is of particular benefit for preventing falls. A Cochrane Review written in 2009 which performed a meta analysis of four tai chi trials found that people who did tai chi had a 35% reduced risk of falls relative to controls (risk ratio RR 0.65, 95% CI 0.51 to 0.82).

They said that exercise programmes that help endurance and flexibility are of benefit, but not on their own, and that exercises that target balance and gait are also important. They said that in most of the exercise trials that had shown a positive effect the programme was longer than 12 weeks (up to three times a week) with varied intensity. However, they highlight that exercise programmes should be initiated carefully for individuals with limited mobility and who were not used to physical activity. This is because some studies have shown that exercise may increase the number of falls in this group.

The panel also made some other recommendations in addition to exercise programmes:

  • “Medication reduction is stressed for all older people, not only for those taking four or more medications, as in the earlier guidelines.” They say that medications have consistently been associated with a risk of falls, and the strongest risks were associated with psychotropic drugs (drugs affecting the brain) or a mixture of drugs. Reducing psychotropic drugs reduces the risk of falls.
  • Assessment and treatment of posture-dependent low blood pressure (which may lead to fainting) should be given to those with a history of falling. Postural low blood pressure may be caused by dehydration, some medications or nerve problems. It can be treated with strategies such as hydration, elastic stockings or medications.
  • Vitamin D (at least 800 IU per day) is recommended for all older adults at risk of falls and suspected of having vitamin D deficiencies.
  • Foot problems, such as moderate to severe bunions, toe deformities, ulcers or deformed nails may make it more likely that an older person will fall. Steps should be taken to ensure that individuals have appropriate, well-fitting shoes, with a low heel height and high surface contact area.

The panel said that there was insufficient evidence (i.e. high quality studies had not been performed) to support any recommendations to reduce fall risk in people who had cognitive impairments.

 

How did the researchers interpret the results?

The panel made a series of recommendations and provide a flow diagram summarising the actions and decisions to be made by those professionals involved in the prevention of falls in older people who live in the community (outside hospital).

 

Conclusion

This guideline recommends that a risk assessment of falling in the elderly should be routinely performed. It outlines some prevention strategies including exercise programmes, such as tai chi, which may help to lower the risk of falls. The guideline also outlines other practical measures, supported by evidence, which can help to reduce the risk of falls. These include maintaining and providing treatments for good foot and heart health, wearing appropriate shoes and making sure elderly people have sufficient vitamin D for bone health and strength.

As a joint American and British publication, this guideline will carry some weight among professionals involved in the care of the elderly in both countries. In terms of implementation, the overall cost of tai chi programmes and how they could be efficiently supplied to large numbers of elderly people will need to be considered.

Elderly people who are unused to exercise should consult with their doctor about appropriate exercise programmes for them to start with.

Analysis by Bazian

Edited by NHS Choices

Links to the headlines

Tai Chi prevents elderly falls say geriatrics societies, BBC News, January 14 2011

Take up tai chi to prevent falls, elderly toldThe Daily Telegraph, January 14 2011

Links to the science

Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons, Journal of the American Geriatrics Society. First published online: January 13

 

Further reading

Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community, Cochrane Database of Systematic Reviews 2009, Issue 2

Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in nursing care facilities and hospitals, Cochrane Database of Systematic Reviews 2010, Issue 1

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