Older people with dementia have a higher risk of falls and fall-
related injuries compared with older people in general.1e3 The
increased risk can be attributed to symptoms such as cognitive and
physical impairment.1,3,4 Furthermore, people with non-Alzheimer’s
types of dementia (non- Alzheimer’s disease), for example, Lewy body
dementia and vascular dementia, seem to have a higher fall risk
compared with Alzheimer’s disease.1,5 Consequences of falls (eg, hip
fractures) can have a detrimental influence on functional ability and
survival in older persons,6 let alone persons with dementia, who,
following a hip fracture, appear to have even worse prognosis than
those without dementia.2,7,8 The number of older people with de-
mentia is projected to increase in the near future, and falls and fall-
related injuries not only contribute to the burden of illness, but will
also challenge public health resources worldwide.
In community-dwelling older populations, there is evidence that
physical exercise, as a single intervention, can prevent falls.9,10 Exer-
cise programs involving a high challenge to balance and performed at
least 3 times a week seem to have the greatest fall preventative ef-
fect.10 Also, in older people with cognitive impairment, promising
evidence of the effect of exercise on falls prevention is emerging.10,11
However, studies in people with dementia are comparatively few,
and most are set in the community.12e14 In nursing homes, where a
large proportion of the residents have dementia, there is limited ev-
idence of beneficial effects of exercise.10,15 Furthermore, improved
ability to ambulate independently may pose a higher risk of falls and
fall-related injuries through an increased exposure to high-risk
situations.15e17
Beneficial effects on balance of a high-intensity functional exercise
program in people with dementia living in nursing homes have been
found previously. The program appeared to particularly benefit par-
ticipants with non-Alzheimer’s disease compared with people with
Alzheimer’s disease,18 while no effects were observed on cognition.19
In addition, in older people with and without dementia living in
nursing homes, exercise programs have been shown to prevent falls
when balance was improved.20 The aim of this study was, therefore, to
investigate the effects of a high-intensity functional exercise program
on fall rate in people with dementia living in nursing homes, and if
effects were associated with sex, dementia type, or improvement in
balance. A further aim was to describe the occurrence of fall-related
injuries.
Methods
This study was part of the Umeå Dementia and Exercise Study
(UMDEX), a cluster-randomized controlled trial, set in 16 nursing
homes in Umeå, Sweden.18,19,21 The study protocol (ISRCTN31767087)
is published on the ISRCTN registry.
Participants
The UMDEX study included nursing home residents who had a
Mini-Mental State Examination (MMSE) score of at least 10,22 a de-
mentia diagnosis, 23 were aged 65 years or over, dependent on assis-
tance in at least 1 personal activities of daily living (ADL) according to
the Katz Index,24 had the ability to stand up from a chair with armrests
with assistance from no more than 1 person, physician’s approval, and
ability to hear and understand spoken Swedish sufficiently to partic-
ipate in assessments. All participants gave informed oral consent,
which was also confirmed by their next of kin. In the 864 nursing
home residents screened in total, age (P ¼ .189) and MMSE score
(P ¼ .713) did not differ between participants included and those who
declined participation (n ¼ 55; Figure 1). A larger proportion of men
than women declined participation (34% vs 18%; P ¼ .008).
Sample and Randomization
Sample size (n ¼ 186) for the UMDEX study was calculated based
on the main outcome, the Barthel ADL Index.18 In addition, a power
simulation was undertaken using data on participants with dementia
from a previous trial investigating exercise effects on falls,20 which
assumed a dispersion parameter of 2.0, a control group fall rate of 5.0
falls/person-year, and a 30% difference in fall rate between groups. A
sample size of 135 participants was required to have a 80% chance of
detecting such reduction in fall rate significant at the 5% level.
Participants were randomized after completion of enrolment
process and baseline assessment to ensure concealed allocation.
Clusters (n ¼ 36) of 3 to 8 participants each (who lived in the same
wing, unit, or floor) were formed to reduce contamination. The
randomization was stratified in all nursing homes except one that had
only a single cluster; the object being to have participants in both
exercise and attention control groups living in each nursing home,
which reduces the risk of site-specific factors influencing the outcome.
Two researchers not involved in the study performed randomiza-
tion by drawing lots using sealed opaque envelopes. The Regional
Ethics Review Board in Umeå approved the study (2011-205-31M).
Intervention
Physiotherapists (PT) led the exercise activities, and occupational
therapists (OT) or an OT assistant led the attention control activity.
Following exercise recommendations for general older populations,
the intervention consisted of 5 sessions per fortnight for the duration
of 4 months (40 sessions in total), with each session lasting approxi-
mately 45 minutes. Whenever possible, supervised individual sessions
were offered when participants were unable to attend a group session.
No activities were provided after the 4-month intervention. Partici-
pation in activities other than those provided by the study was not
restricted at any time.
The exercise intervention was based on the high-intensity func-
tional exercise program (HIFE), which includes a model for exercise
selection and a definition of exercise intensity (available online at
https://www.hifeprogram.se/en).18,25,26 In brief, the HIFE comprises
39 functional exercises for improved lower limb strength, balance,
and mobility to be performed with high intensity and in weight-
bearing positions similar to daily activities. High-intensity in
strength exercise is defined as 8e12 repetition maximum and in
balance exercise when postural stability is fully challenged.25,26 Ex-
ercises were tailored based on participants’ functional deficits. Par-
ticipants were supervised individually to promote the highest possible
exercise intensity, and adapted accordingly through progressive
adjustment of load and base of support, while also taking into account
participants’ symptoms and changes in health and functional status.
For safety, participants wore belts with handles so that PTs could
provide support if needed when postural stability was fully chal-
lenged, thereby preventing falls. Unnecessary support was avoided.
The attention control group participated in structured activities
that were developed by the OTs/OT assistant that led the activities. The
activities were structured around topics believed to be interesting for
older people, including local wild life, seasons, and holidays. While
seated in a group, participants conversed, sang, listened to music or
readings, and/or looked at pictures and objects.
At the end of each session, leaders completed a structured protocol
for each participant pertaining to adverse events, and in the exercise
group, intensity achieved in muscle strength and balance exercises,
which was estimated separately as high, moderate, or low according to
the predefined scale.25 All adverse events recorded during exercise
sessions were minor or temporary.27 In the exercise group, partici-
pants performed strength exercises with moderate intensity (40%)
and at high intensity (49%) of attended sessions, and balance exercises
A. Toots et al. / JAMDA 20 (2019) 835e842836

The Effects of Exercise on Falls in Older People

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