Table 12.1 lists commonly reported risk factors for falls (Lord et al 2007). Many of these factors are also risk factors for functional decline (Dunlop et al 2005).

Table 12.1 Risk factors for falls and functional decline

RISK FACTOR	FOR FALLS	FOR FUNCTIONAL DECLINE
Past history of a fall	✓	✓
Age	✓	✓
Female gender	✓	✓
Lower extremity weakness	✓	✓
Balance problems	✓	✓
Low levels of physical activity	✓	✓
Cognitive impairment	✓	✓
Psychotropic drug use and/or polypharmacy	✓	✓
Chronic medical problems such as arthritis, stroke or Parkinson’s disease	✓	✓
Sensory loss, including vision and somatosensory loss	✓	✓
Orthostatic hypotension	✓
Acute health problem such as pneumonia, urinary tract infection	✓
Dizziness	✓
Diabetes		✓
Depression	✓	✓
Incontinence	✓	✓

Incidence, contributory factors and impact of low levels of physical activity and functional decline

Physical activity — often also called exercise — refers to any task that is associated with some level of energy expenditure. Some tasks, such as standing up from a chair or showering, involve relatively little energy expenditure, while other tasks such as mowing lawns, playing tennis or group exercise programs can involve relatively high levels of energy expenditure.

Low level of physical activity is responsible for about 7% of the burden of preventable health problems and disability, and between 1.5–3% of total direct health care expenditure (Mathers et al 1999; Oldridge 2008). Physical inactivity is a risk factor for a range of health problems and functional limitations, including increased risk of falls (Lord et al 2007) and increased risk of cardiovascular disease, stroke, diabetes and some forms of cancer (Warburton et al 2007). Less than 50% of older people are sufficiently active to achieve health benefits (defined as up to 30 minutes per day of moderate or vigorous activity on most days of the week, or an accumulation of 150 minutes per week), with physical activity rates higher in older men than older women (Armstrong et al 2000; Bauman et al 2003). Therefore strategies to improve older people’s participation in physical activity have the potential to achieve a range of health benefits.

Strategies to improve older people’s participation in physical activity have the potential to achieve a range of health benefits.

Physical activities can vary in their intensity, and are often classified as light, moderate or vigorous physical activity.

• Light physical activities are those that are associated with minimal physical exertion, and do not cause any noticeable change in heart rate or breathing while doing the activity.

• Moderate physical activities are those that cause the heart to beat faster and some shortness of breath, but the person can still talk comfortably while doing the activity.

• Vigorous physical activities are those performed at a level that causes the heart to beat a lot faster and causes shortness of breath that makes talking difficult between deep breaths.

Moderate or vigorous intensity physical activities are required to achieve improved health outcomes (Glasgow et al 2005).

There are many ways for older people to become or remain physically active. These can be grouped broadly as incidental activities or organised activities. Incidental activities are activities that involve some degree of physical exertion, but are undertaken as part of routine activities. They include activities such as gardening, vacuuming, walking to the local shops instead of driving and taking the stairs instead of the elevator. Incidental activities, particularly when performed at moderate intensity level, contribute to the cumulative amount of physical activity a person performs each day.

Organised physical activity refers to more formal approaches to exercise. These are often in a group setting. Research has shown that many types of organised physical activity can achieve positive outcomes for older people, including those with health problems. Health benefits include:

• improved muscle strength

• improved balance and reduced falls

• improved functional abilities

• improved cardiovascular fitness

• reduced risk of health problems such as diabetes, some cancers, and cardiovascular problems such as stroke and heart attack

• slower loss of bone structure and strength

• improved mood and reduced depression (King et al 1998; Nelson et al 2007).

There are many approaches to organised physical activity. These include:

• multi-faceted group exercise programs, often including strengthening, balance, fitness and flexibility exercises

• tai chi programs

• strength training programs or cardiovascular fitness programs at gymnasiums

• hydrotherapy (exercise in water) programs

• walking programs.

Many recreational activities also have a physical component to them, and are likely to have some health benefits associated with them as well, although these have been less well researched. For example, dancing, lawn bowls and golf have all been shown to have some associated health benefits, as well as having strong benefits for older people from social and connectedness perspectives.

A specific type and intensity of physical activity will be of different challenge to older individuals depending upon their current level of fitness and their concurrent health problems. As such, a regular game of lawn bowls or bocci might have limited effect on health for a well older person (who would probably require a more physically taxing activity to achieve health benefits), however might be suitable and have some health-promoting effects for some less well older people. For a frail older person with multiple comorbidities however, this activity level might not be possible (see Fig 12.1).

Figure 12.1 Physical activity options across the health continuum

Even frailer older people who have a range of acute or chronic health problems can still be involved in physical activity programs and derive positive health outcomes. For example, older people with stroke (van Peppen et al 2004), arthritis (Keysor & Jette 2001), Parkinson’s disease (de Goede et al 2001) and those with increased risk of falls (Sherrington et al 2004) have been shown to safely and effectively participate in physical activity programs. However, people with these health conditions should discuss commencing participation in a new form of physical activity with their general practitioner or other health professional, and it is often preferable for these people to commence an exercise program under supervision of a trained exercise leader such as a physiotherapist, accredited exercise leader or exercise physiologist (Nelson et al 2007).

Even frailer older people who have a range of acute or chronic health problems can still be involved in physical activity programs and derive positive health outcomes.

There are many associated benefits of participating in physical activity in group settings. The social interactions and networking that occur during exercise groups have been highlighted as key factors influencing longer-term participation (Vrantsidis et al in press). However, some older people prefer to undertake physical activity alone. Many of the approaches to exercise described above (e.g., strengthening exercises, balance exercises, walking programs, tai chi) can be performed at home alone, sometimes with intermittent support (e.g., DVD of the tai chi movements), particularly after initial training with an exercise leader. Individualised exercise programs targeting balance and muscle strength problems might also be recommended as a home program. These are often prescribed after a comprehensive musculoskeletal assessment by a health professional, such as a physiotherapist. Home exercise programs incorporating balance and strengthening exercises have been shown to be effective in improving balance and muscle strength and reducing falls (Robertson et al 2002). Both group exercise programs and individualised home exercise programs have been shown to achieve positive health outcomes. Personal preference, safety issues, comorbidities and the desired health outcomes are important considerations in determining the type, location and intensity of an exercise program for an individual.

Age alone is not a barrier to participation in any form of physical activity. The number of concurrent health problems is a much stronger determinant of the type and level of physical activity an older person can undertake safely. Some well older people can continue to participate in quite vigorous physical activity (Nelson et al 2007) such as long-distance running or swimming.

Indicators (observational cues, without assessment) of functional decline and falls risk

VIGNETTE 1: Mary Johnson (Part 1)

Julie is a home care worker. She has been visiting Mary Johnson, an 86-year-old lady living alone at home, twice weekly for 6 months since Mary returned home after rehabilitation following a small stroke. Julie has noticed in the past few visits a number of changes with Mary. These include that she has started using a walking stick that she bought at the pharmacy, that she has recently stopped walking to the local shops and that she is having increased difficulty standing up from chairs. Before reading on, consider what possible risk factors for falls and functional decline these observations might indicate.

Referring to Table 12.1, these changes suggest possible reduced balance (need for the walking stick), reduced leg muscle strength (difficulty standing up from a chair), reduced activity level and possible loss of confidence (not walking to shops any more).

To further explore these risk factors, and determine the best strategies to reduce risk of falling and risk of further decline in function, Julie recommends that Mary see her local doctor, and reports these observations to her manager.

Table 12.2 describes many of the indicators of modifiable risk factors for falls and functional decline (including low level of physical activity) and some cues that might indicate that the person is at increased risk and would benefit from assessment by a health professional assessment and a management program.

Table 12.2 Indicators of modifiable risk factors for falls or functional decline

RISK FACTOR	OBSERVATION, CUE OR INDICATOR^∗
Past history of a fall	Observation of bruising or other injuries, apparent loss of confidence, direct questioning about falls.
Lower extremity weakness	Effort associated with standing up from a chair, needing to push up when standing up.
Balance problems	Unsteady or veering during transfers or walking, experiencing near falls, ‘furniture walking’, unsteady or overbalancing during reaching, bending or turning.
Low levels of physical activity	Obtain history of activities performed 12 months ago, compare to current activity level. Recent changes in activity level.
Psychotropic drug use / polypharmacy	Unsteadiness developing soon after commencing new medications, falls at night, presence of symptoms that might be side effects of some medications (e.g., dizziness, low blood pressure when standing up).
Chronic medical problems such as arthritis, stroke or Parkinson’s disease	Check medical history.
Sensory loss, including vision and somatosensory loss	Vision — inability to see detail, spilling drinks, bumping into objects, tripping, not wanting (or inability) to read or watch television. Somatosensory — poor skin condition, cuts or scratches on feet, lack of feeling in the feet.
Orthostatic hypotension	Light headedness or unsteadiness when sitting up from lying, or standing up from sitting or lying.
Acute health problem such as pneumonia, urinary tract infection	Sudden change in health status.
Dizziness	Spinning sensation, especially when turning quickly, can be associated with nausea and vomiting.
Diabetes	Weight loss, excessive urination, excessive thirst, fatigue, vision problems.
Depression	Lethargy, loss of appetite, loss of interest in activities, difficulty concentrating on tasks.
Incontinence	Frequent need for toileting, poor fluid intake, urinary or bowel accidents, nocturia, strong odour of urine.

∗ from the Victorian Quality Council (Hill et al 2004). Website: www.health.vic.gov.au/qualitycouncil/downloads/falls/reference.pdf

Screening and assessment for activity level and falls risk

When there are indicators of potential risk factors for functional decline or risk of falls (such as those described in Table 12.2), there is then a need to determine the extent and causes of the risk factors. This will usually involve either a screening or assessment procedure. Screening or assessment can help to confirm presence of risk factors for falls or functional decline, and provide a framework for developing an individualised management or prevention program.

Screening is a brief process, often only up to five items, used to grade overall risk and determine if a comprehensive assessment is required, but usually does not provide sufficient details on which to develop a care plan to minimise overall risk. In contrast, an assessment is usually comprehensive, and investigates risk factors in detail.

Screening and assessment for low levels of physical activity / functional decline

For a detailed profile of physical activity either to assist with identifying specific areas of need, or to use in tailoring a physical activity program, more detailed physical activity assessments are required (Melanson & Freedson 1996). Examples of physical activity questionnaires include the 94 item Human Activity Profile (Fix & Daughton 1988) and the CHAMPS tool (Cyarto et al 2006). A new assessment tool that provides a measure of function, mobility, and balance performance is the de Morton Mobility Index (DEMMI). This tool has recently been shown to be a useful assessment of function in older people in hospital (de Morton et al in press).

Screening and assessment for falls risk

One of the strongest risk factors for having a future fall and for functional decline is having had a previous fall, even if the fall did not cause an injury. However many older people do not report falls to their general practitioner or health professional. One of the most useful single items in a screening tool, even by itself, is to ask whether an older person has had a fall in the preceding 12 months. If they have, then this should be further investigated by the health professional and a treatment plan implemented if risk factors are identified.

One of the strongest risk factors for having a future fall, and for functional decline, is having had a previous fall.

An example of a falls risk screening tool (the FROP-Com screen) is shown in Figure 12.2 (Russell et al in press). This is a three-item screen for older people living in the community that was developed from a validated falls risk assessment tool (the Falls Risk for Older People — Community version: FROP-Com), shown in Figure 12.3 (Russell et al 2008). The FROP-Com screen has been used in a range of community-based settings, including older people with low falls risk (Murray et al 2005) and high falls risk (Russell et al 2006). Other assessment tools have been reported for use in residential care settings (Lundin-Olsson et al 2003) and in hospital settings (Haines et al 2007). The presence of fear of falling should also be considered for those at risk of falls, or who have had a recent fall. A screening question may be just to ask: ‘As a result of the fall or near fall, have you lost confidence in walking and other activities?’ For those who report positively, a detailed assessment of fear of falling (also called falls efficacy) should be undertaken. The Short Falls Efficacy Scale International (Short FESI) is a recently developed abbreviated assessment tool to measure fear of falling (Kempen et al 2008).