Fall prevention: Life and longevity, part 4

Aging and falls go hand in hand. In Canada/globally, falls are a serious public health concern. “Falls remain the leading cause of injury-related hospitalizations among Canadian seniors, and between 20% and 30% of seniors fall each year. Falls and associated outcomes not only harm the injured individuals but also affect family, friends, care providers and the health care system. However, we do know that these personal and economic costs can be avoided through injury prevention activities. In addition to the negative physical and mental health consequences of falling, there are significant associated financial costs, estimated at $2 billion annually, a value 3.7 times greater than that for younger adults.”(1)

The Nagi Model outlined that the aging person maybe dealing with some disease pathology and lifestyle activity factors. These contribute to impairments such as balance issues, muscle weaknesses, sarcopenia, cardio/respiratory endurance deficits, decreased flexibility/ROM and decreased reaction times, to name a few. Because of all these factors, it was stressed in “part 2” that a good consultation/physical and aging assessment tools should be used to specifically identify which body area/system, maybe most compromised.

Without exercise or regular physical activity, muscles will age more quickly. This will lead to decreased muscle mass, strength, the ability of muscle to regenerate and impairment in muscle metabolism. Exercise and physical activity should be emphasized as part of a lifestyle essential to healthy aging.(2) Studies have shown that exercise as a single intervention is effective in preventing falls, and the more exercises done the better the results in decreasing falls/fractures and increasing leg strength and balance.(3, 4) Studies have shown that multimodal programs are beneficial for older adults.(5, 6) Improvement in functional abilities would imply that the potential for falls would decline. In addition, the patient should be advised to assess their home environment for areas that can contribute to missed steps, balance issues and falls. Patients should become more aware of their environment, both at home and in the community.

One of the key physiological impairments that occurs with ageing is the loss of lower limb strength and the slowing of mobility. Both of these are tied in with atrophy of Type II muscle fibers, which equate to loss of strength and speed. Falls happen when an aging person loses their balance and cannot quickly regain it, by a quick leg re-position or fast postural adjustment. Aging causes a reduction in the proportion of less efficient fast-twitch Type II skeletal muscle fibers and subsequently a greater propensity for falls. Strength and speed training can increase both work efficiency and Type II skeletal muscle fiber size and percentage in the elderly, which will support both physical function and fall prevention in this population.(7) Other factors will contribute to the effective function of the Type II skeletal muscle fiber, such as calcium. Lack of calcium and aging affects muscle cells power output.(8) The aging person needs to be taking adequate amounts of calcium. Certain types of exercises such as jumping, help to maintain the conduction velocity, ie. the propagation of the action potential, especially in Type II muscle fibers.(9)

For the nervous system, certain areas of the brain such as the prefrontal cortex activity levels can also contribute to the progression of falls (10) and neuromuscular control and step to step variability.(11) As well, the amount of sleep the aged person achieves each night(12), important, as this ties in to the level of melatonin released in the system. The better levels of melatonin will positively affect skeletal muscle frailty and help to improve physical exercise performance.(13).

The research literature regarding fall prevention, states that a good program should address as many components as possible, and when this is done, even in a short program, will still be beneficial for fall prevention.(14) Reduced ability to adapt gait, particularly under challenging conditions, may also be an important reason why older adults have an increased risk of falling.(15) Introducing variable surface patterns into the gait training, along with balance, cognitive and behavioral components, would contribute significantly to decreasing falls in the aging person.(16)

Having a comprehensive multimodal program, which is short and covers all the major systems for the aging person, such as muscle training, neuromuscular co-ordination, cardiorespiratory, core and cognitive areas, seems to be the way to go. Remember the aging person has limited energy and cognitive abilities, such as focusing and concentration. A comprehensive program could be broken up into small segments which could be done daily for short periods. The patient will achieve maximum benefits over a 6-8 week training program.(17).

Plyometrics will benefit the Type II muscle fibres, increasing strength and speed to lower limb muscles, improve cardiorespiratory function and general body strength, balance and cognition. Plyometrics could be done on alternate days and each week the duration and intensity (height of jump), could be gradually increased. This will easily fit into their time constrain requirements. In addition, supplementing with Vitamin E which has been shown to benefits myoblast proliferation, differentiation, survival, membrane repair, mitochondrial efficiency, muscle mass, muscle contractile properties, muscle strength and increase exercise capacity.(18) When adequate protein intake and Vitamin D are added, these four factors will contribute significantly to the functional performance of the aging person.

References

1. https://www.canada.ca/en/public-health/services/health-promotion/aging-seniors/publications/publications-general-public/seniors-falls-canada-second-report.html
2. Distefano G, et al. Effects of Exercise and Aging on Skeletal Muscle. Cold Spring Harb Perspect Med . 2018 Mar 1; 8(3): a029785.
3. Sherrington C, et al. Exercise to Prevent Falls in Older Adults: An Updated Systematic Review and Meta-Analysis. Br J Sports Med. 2017 Dec; 51(24): 1750-1758.
4. Zhao R, et al. Exercise Interventions and Prevention of Fall-Related Fractures in Older People: A Meta-Analysis of Randomized Controlled Trials. Int J Epidemiol. 2017 Feb 1; 46(1): 149-161.
5. Morat M, et al, Agility Training to Integratively Promote Neuromuscular, Cognitive, Cardiovascular and Psychosocial Function in Healthy Older Adults: A Study Protocol of a One-Year Randomized-Controlled Trial. Int J Environ Res Public Health. 2020 Mar 12; 17(6): 1853.
6. Shahtahmassebi B, et al. Trunk Exercise Training Improves Muscle Size, Strength, and Function in Older Adults: A Randomized Controlled Trial. Scand J Med Sci Sports. 2019 Jul; 29(7): 980-991.
7. Wang E, et al. Impact of maximal strength training on work efficiency and muscle fiber type in the elderly: Implications for physical function and fall prevention. Exp Gerontol. 2017 May; 91:64-71.
8. Straight C, et al. Age-related reduction in single muscle fiber calcium sensitivity is associated with decreased muscle power in men and women. Exp Gerontol. 2018 Feb;102:84-92.
9. Methenitis S, et al. Muscle Fiber Conduction Velocity, Muscle Fiber Composition, and Power Performance. Med Sci Sports & Exercise. . 2016 Sept. 48(9):1761–1771.
10. Verghese J, et al. Brain activation in high-functioning older adults and falls: Prospective cohort study. Neurology. 2017 Jan 10; 88(2): 191-197.
11. 1\Allen J, et al. The Motor Repertoire of Older Adult Fallers May Constrain Their Response to Balance Perturbations. J Neurophysiol . 2018 Nov 1; 120(5): 2368-2378.
12. Vincent B, et al. Sleeping Time Is Associated With Functional Limitations in a National Sample of Older Americans. Aging Clin Exp Res . 2020 Mar 13.
13. Stacchiotti A, et al. Impact of Melatonin on Skeletal Muscle and Exercise. Cells. 2020 Jan 24; 9(2): 288.
14. Losa-Reyna J, et al. Effect of a short multicomponent exercise intervention focused on muscle power in frail and pre frail elderly: A pilot trial. Exp Gerontol. 2019 Jan; 115: 114-121.
15. Caetano M, et al. Executive Functioning, Concern About Falling and Quadriceps Strength Mediate the Relationship Between Impaired Gait Adaptability and Fall Risk in Older People. Gait Posture. 2018 Jan; 59: 188-192.
16. Montero-Odasso M, et al. Falls in Cognitively Impaired Older Adults: Implications for Risk Assessment And Prevention. J Am Geriatr Soc. 2018 Feb; 66(2): 367-375.
17. Donath L, et al. Exercise-Based Fall Prevention in the Elderly: What About Agility? Sports Med. 2016 Feb; 46(2): 143-9.
18. Chung E, et al. Potential Roles of Vitamin E in Age-Related Changes in Skeletal Muscle Health. Nutr Res. 2018 Jan; 49: 23-36.

Dr. Don Fitz- Ritson is a chiropractor and a rehab specialist. He was an Assistant Professor at CMCC. He published 17 papers and 3 chapters on chiropractic.He co-invented a laser and it received 7 Health Canada Approvals. He is focused on helping the aging population live better lives.