Evaluating Exercise for Fall Prevention in Dementia: A Nursing Report

This report assesses the clinical effectiveness of mild to moderate physical exercise in reducing the risk of accidental falls among older adults with dementia. It begins by identifying aged care as a specific area of interest, given the increasing elderly population and the prevalence of dementia, which elevates the risk of falls. A PICO question is formulated to guide the research, focusing on the impact of physical exercise on fall incidence in this population. The research employs databases like CINAHL and PubMed, utilizing keywords related to physical activity, falls, dementia, and older adults, with inclusion and exclusion criteria set for study selection. Three articles, including a randomized controlled trial and systematic reviews/meta-analyses, are critically evaluated for their methodologies and findings. The report discusses the barriers to implementing exercise programs, such as lack of interest, physical limitations, and the need for tailored interventions, highlighting the importance of addressing individual preferences and co-morbidities. The overall conclusion emphasizes that while physical exercise can be effective in reducing falls, its success depends on considering factors like age, gender, and the setting in which the intervention is implemented. Desklib provides access to similar solved assignments and past papers for students.

Running head: NURSING
Assessment Task 3
Name of the Student
Name of the University
Author Note

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Assessment Task 1
The specific area of practice in which I have particular interest is aged care.
According to the World Health Organization (WHO) (2019), in the coming decade, the
percentage of the elderly population is going to double (from 12% to 22%) and thus
outnumbering the percentage of children who are younger than 5 years. Increase in the
percentage of older adults is associated with several age health-related conditions commonly
known as geriatric syndromes. One of the common geriatric syndromes is dementia.
Dementia is a neurodegenerative disorder that has no cure. Older adults who are suffering
from dementia experience frailty and are vulnerable to accidental falls. Petersen et al. (2018)
and Fernando et al. (2017) stated that dementia doubles the risk of fall among the older adults
living at home or under residential care set-up or assisted care living. Encountering accidental
fall leads to fatal injuries and thereby hampering the health-related quality of life. This
highlights the need for further effective fall prevention of along with interventions for falls
especially for the older adults with dementia. A critical review of literature is important in
order to evaluate the clinical effectiveness along with the cost-effectiveness of fall prevention
initiatives among the older adults with dementia. The main domains of the fall prevention
strategy that will be targeted include mild to moderate physical exercise. The systematic
review conducted by Fernando et al. (2017) showed that the risk factors like balance, gait,
vision and functional status increase the vulnerability of accidental fall among the older
adults with dementia. Wheatley et al. (2019) revealed in their study that physical exercise in
general is helpful for adults to increase the level of physical fitness, irrespective of their age.
Thus, the main intervention that will targeted in this study is mild to moderate physical
exercise for the older adults.

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Task 2
Research Question
What is the clinical effectiveness of mild to moderate physical exercise over the older adults
with dementia for decreasing the vulnerability of accidental fall?
PICO question
Population (P) Older adults with dementia
Intervention (I) Physical exercise as fall prevention strategies
Comparison (C) No physical exercise
Outcomes (O) Decreased incidence of accidental falls
Conduction of Research
Databases selected for research
CINAHL and PubMed
Keywords used for database research
Keyword 1: Physical exercise OR Physical activity OR exercise
[AND]
Keyword 2: Risk of falling OR Accidental fall OR Falls
[AND]
Keyword 3: Dementia OR Alzheimer
[AND]
Keyword 4: Older adults OR Aged care OR Geriatric OR Old

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Inclusion and Exclusion Criteria
Inclusion Criteria Exclusion Criteria
Population: Older adults who are above 60 years
of age
Below 60 years of age
Disease: Dementia Or Alzheimer Or Cognitive
impairment
Not significant disease condition
Intervention: Physical exercise Other intervention apart from physical exercise
Language: English Apart from English
Type of Paper: Both Qualitative and Quantitative Grey literatures and Dissertation and Case studies
Year of publication: Last 10 years (2010 to 2020) Papers published before 2010
Peer-reviewed Non-peer-reviewed
List of three selected articles highlighted through database search
Sr.
No.
Level of
Evidence
List of Papers Justification Behind selection
1 Level 1b Toots, A., Wiklund, R., Littbrand, H.,
Nordin, E., Nordström, P., Lundin-Olsson,
L., ... & Rosendahl, E. 2019, ‘The effects of
exercise on falls in older people with
dementia living in nursing homes: A
randomized controlled trial’, Journal of the
American Medical Directors
Association, vol. 20, no. 7, pp. 835-842.
Falls under level 1b of hierarchy. I
has conducted randomized control
trial and this helps to retrieved
unbiased results in comparison to
the other study design
2 Level 1a Burton, E., Cavalheri, V., Adams, R.,
Browne, C.O., Bovery-Spencer, P., Fenton,
A.M., Campbell, B.W. & Hill, K.D., 2015,
‘Effectiveness of exercise programs to
reduce falls in older people with dementia
living in the community: a systematic review
and meta-analysis’, Clinical interventions in
Falls under Level 1a of hierarchy
and selected peer-reviewed articles
that are published within 14 years
(2000 to 2014) and thus increasing
the strength of the review

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aging, vol. 10, p.421.
3 Level 1a Hamed, A., Bohm, S., Mersmann, F. &
Arampatzis, A., 2018, ‘Follow-up efficacy of
physical exercise interventions on fall
incidence and fall risk in healthy older
adults: a systematic review and meta-
analysis’, Sports medicine-open, vol. 4, no.
1, p.56.
Falls under level 1a of hierarchy of
evidences and have reviewed 26
studies in told and thus helping to
get generalized results
Table: Hierarchy of Evidence
(Source: Ingham-Broomfield et al. 2019)

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Figure: Screen shot of CINAHL database search
Task 3
Toots et al. (2019) conducted randomized control trial in order to investigate the
effects of exercise in promoting fall prevention among the older adults with dementia living
in the nursing homes. The authors also studied whether the effects of the physical activity
varies with sex, type of dementia and the gait balance. A cluster randomized control trial was
conducted by selected a total of 141 women and 45 men from 16 different nursing homes
with the mean age group of 85 years. The large sample size and selection of the candidates
from different institution helped to attain diversity in the sample population and this helping
to promote generalization of the results (Hariton & Locascio, 2018). However, there was lack

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of parity between men and women with number of women 100% higher than men and thus
increasing the gender level bias in the study results. All the older adults scored 15 in the mini-
Mental State examination and thus indicating the severity of dementia. The randomization
during the selection of the sample helped to reduce the chances of selection bias. The
experimental group was asked to perform high-intensity functional program and other group
was asked to perform seated attention control activity for 2 to 3 times per week for at least 4
months. The analysis of the results after 6 months of follow-up showed that high intensity
functional exercise program alone is not effective enough for reduction in the intensity of fall
in comparison to the attention control group. The authors stated that among the high-risk
older adults with dementia, multi-morbidity and polypharmacy are common. Thus, a multi-
factorial fall-prevention approach might prove to be more effective. Thus it can be stated that
overall randomized control trial failed to show any significant effectiveness of physical
exercise for the prevention of fall. Wanigatunga et al. (2017) stated that older adults how are
above 80 years are age are in capable of conducting high-intensity physical activity.
Wanigatunga et al. (2017) further stated that if the older adults have no previous experience
of conducting physical activity during their young adult stage then adaptation of high-
intensity physical activity can be prove to be difficult. Moreover, a significant group of
population was women in this study and Imtiaz et al. (2017) stated that women after
menopause are physically weak to take active part in high intensity physical activity. These
two reasons must be considered as two of the pillars behind the failure of the study of Toots
et al. (2019) to fetch significant results.
However, the results of the two systematic review/meta-analyses that have been
selected through literature search helped in the identification of different results in
comparison to the result of Toots et al. (2019). Burton et al. (2015) conducted systematic
review and meta-analysis in order to evaluate the overall effectiveness of the physical

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exercise program for the reduction of accidental falls among the older adults with dementia
residing under community level settings. Thus, the sample selection was different from Toots
et al. (2019) as selected nursing home candidates. Only peer-reviewed randomized control
trial (RCTs) and quasi-experimental trials published in English during 2000 to 2014 were
selected for the study. The papers were retrieved from 6 different databases. Selection of the
papers within the time-frame of 14 years and from 6 different databases helped to increase
the probability of randomization and to obtain a vast access of data leading to generalization
of the results. However, the authors were only successful in recruiting a total of 4 articles and
this poor sample size restricted the generalization of the results further (Bothwell et al.,
2016). The systematic review and meta-analysis of the articles indicated that exercise
program might help in assisting fall prevention among the older adults with dementia, living
in the community. However, the authors stated that further research is required to be
undertaken with the large sample size along with standardized measurement outcomes, longer
tenure of follow-ups for promoting evidence-based recommendations. The success of this
meta-analysis/systematic review by Burton et al. (2015) in comparison to the Toots et al.
(2019) is, the authors selected only limited papers and the age limit of the participants were
60 years and above. The limited sample size is the reason why this paper is not suitable for
including under evidence-based practice. Several different kinds of interventions were
focused in this study like group-based intervention and home-based interventions. The
authors however failed to highlight how effective types of the physical exercise interventions
helped in modulating the affect of fall prevention.
The systematic review and meta-analysis of Hamed et al. (2018) have identical
objective like Burton et al. (2015). Hamed et al. (2018) included studies that are conducted
over the older adults who are 65 years and above and this is slightly different from Burton et
al. (2015). A total of 26 studies were included in the review encompassing 4739 participants

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in total. Thus, the sample size of Hamed et al. (2018) is larger than Burton et al. (2015)
helping in generalization of the results. The results of the review showed that regular practice
of mild to moderate physical activity among the older adults helped in reduction of the fall by
32%, post 12 months of follow-up. The authors further highlighted that posture-challenging
exercise might e considered while designing fall prevention interventions.
Overall, it can be stated that physical exercise can be effective in reducing the chances
of the accidental fall among the older adults. However, the age, gender and the environmental
setting for the implementation of the intervention must be taken into consideration.
Task 4
There are several barriers towards implementation of this evidence-based practice
(EBP) for improving the quality of life of the older adults. According to the Office of Disease
Prevention and Health Promotion (ODPHP) (2011), older adults are well-aware about the
benefits of the physical activity (PA) however, majority of the older adults tend to remain
inactive due to several barriers in effective participation in PA. The first barrier include lack
of interest and this is followed by shortness of breath upon initiation of the physical activity,
joint pain, perceived lack of overall fitness, lack of energy and loss of hope from life. In order
to increase the pro-active initiative to take part in physical activity, the preference of the older
adults must be taken into consideration. The preferences include group-based or individual
activity, indoor/outdoor preferences. This will help in devising customized physical activity
interventions and thus helping to increase the overall outcome. Shortness of breath can be due
to variety of health issues like cardio-vascular disease or long history of smoking. These co-
morbidities must be taken into consideration accordingly to avoid medical complications
(Pettigrew et al. 2019). Furthermore, exercise will help in overcoming joint pain and lack of
fitness. The older adults must be educated about the same and the designing of the PA

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program must be done under the supervision of the trained PA trainer and physio-therapist.
This would help in designing of targeted intensity program. In order increase the energy
level, special health drinks can be prescribed for the older adults along with promoting
mental boost under the counseling of the mental health nurse (Pettigrew et al. 2019).
Bethancourt et al. (2014) stated that the older adult populations can benefit through greater
support and information from their providers and from the health care service systems
regarding safe conduction and maintenance of the PA level during the later part of adulthood.
The overall efforts of the healthcare professionals in order to boost the PA tendencies among
the older adults might need to consider for the promotion of the patient-centered adjustments
towards the current PA program. Geriatric nurses must consider alternative method for
promotion lifestyle changes for promoting the physical activity further.

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References
Bethancourt, H.J., Rosenberg, D.E., Beatty, T. & Arterburn, D.E., 2014, ‘Barriers to and
facilitators of physical activity program use among older adults’ Clinical medicine &
research, vol. 12, no.1-2), pp.10-20.
Bothwell, L.E., Greene, J.A., Podolsky, S.H.& Jones, D.S., 2016, ‘Assessing the gold
standard—lessons from the history of RCT;, The New England Journal of Medcine, vol. 374,
pp: 2175-2181
Burton, E., Cavalheri, V., Adams, R., Browne, C.O., Bovery-Spencer, P., Fenton, A.M.,
Campbell, B.W. & Hill, K.D., 2015, ‘Effectiveness of exercise programs to reduce falls
in older people with dementia living in the community: a systematic review and meta-
analysis’, Clinical interventions in aging, vol. 10, p.421.
Fernando, E., Fraser, M., Hendriksen, J., Kim, C.H. & Muir-Hunter, S.W., 2017, ‘Risk
factors associated with falls in older adults with dementia: a systematic review’,
Physiotherapy Canada, vol. 69, no. 2, pp.161-170.
Hamed, A., Bohm, S., Mersmann, F. & Arampatzis, A., 2018, ‘Follow-up efficacy of
physical exercise interventions on fall incidence and fall risk in healthy older adults: a
systematic review and meta-analysis’, Sports medicine-open, vol. 4, no. 1, p.56.
Hariton, E. & Locascio, J.J., 2018, ‘Randomised controlled trials—the gold standard for
effectiveness research’, BJOG: an international journal of obstetrics and gynaecology, vol.
125, no. 13, p.1716.

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Imtiaz, B., Tuppurainen, M., Rikkonen, T., Kivipelto, M., Soininen, H., Kröger, H. &
Tolppanen, A.M., 2017, ‘Postmenopausal hormone therapy and Alzheimer disease: a
prospective cohort study, Neurology, vol. 88, no. 11, pp.1062-1068.
Ingham-Broomfield, R., 2016, ‘A nurses' guide to the hierarchy of research designs and
evidence, Australian Journal of Advanced Nursing, The, vol. 33, no. 3, p.38.
Office of Disease Prevention and Health Promotion (ODPHP). 2011. Six Barriers to Physical
Activity Participation. Viewed on: 20th January 2020.
https://health.gov/news/blog/2011/04/barriers-to-physical-activity-among-older-adults/
Petersen, J.D., Siersma, V.D., Christensen, R.D., Storsveen, M.M., Nielsen, C.T. & Waldorff,
F.B., 2018, ‘The risk of fall accidents for home dwellers with dementia—A register-and
population-based case-control stud’, Alzheimer's & Dementia: Diagnosis, Assessment &
Disease Monitoring, vol. 10, pp.421-428.
Pettigrew, S., Burton, E., Farrier, K., Hill, A.M., Bainbridge, L., Airey, P., Lewin, G. & Hill,
K.D., (2019), ‘Encouraging older people to engage in resistance training: A multi-stakeholder
perspective’, Ageing & Society, vol. 39, no. 8, pp.1806-1825.
Toots, A., Wiklund, R., Littbrand, H., Nordin, E., Nordström, P., Lundin-Olsson, L., ...
& Rosendahl, E. 2019, ‘The effects of exercise on falls in older people with dementia
living in nursing homes: A randomized controlled trial’, Journal of the American
Medical Directors Association, vol. 20, no. 7, pp. 835-842.
Wanigatunga, A.A., Tudor-Locke, C., Axtell, R.S., Glynn, N.W., King, A.C., Mcdermott,
M.M., Fielding, R.A., Lu, X., Pahor, M. & Manini, T.M., 2017, ‘Effects of a Long-Term
Physical Activity Program on Activity Patterns in Older Adults’, Medicine and science in
sports and exercise, vol. 49, no. 11, pp.2167-2175.

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Wheatley, A., Bamford, C., Shaw, C., Flynn, E., Smith, A., Beyer, F., ... & Homer, T. 2019.
Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID): an integrated,
mixed-methods approach. BMC geriatrics, vol. 19, no. 1, pp: 57.
World Health Organization (WHO). 2019. Ageing and health. Viewed on: 20th January 2020.
https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
Appendix
Toots, A., Wiklund, R., Littbrand, H., Nordin, E., Nordström, P., Lundin-Olsson, L., ... &
Rosendahl, E. 2019, ‘The effects of exercise on falls in older people with dementia living in
nursing homes: A randomized controlled trial’, Journal of the American Medical Directors
Association, vol. 20, no. 7, pp. 835-842.
Abstract
Objectives: To investigate exercise effects on falls in people with dementia living in nursing
homes, and whether effects were dependent on sex, dementia type, or improvement in
balance. A further aim was to describe the occurrence of fall-related injuries. Design: A
cluster-randomized controlled trial. Setting and Participants: The Umeå Dementia and
Exercise study was set in 16 nursing homes in Umeå, Sweden and included 141 women and
45 men, a mean age of 85 years, and with a mean Mini-Mental State Examination score of
15. Intervention: Participants were randomized to the high-intensity functional exercise
program or a seated attention control activity; each conducted 2-3 times per week for 4
months. Measures: Falls and fall-related injuries were followed for 12 months (after
intervention completion) by blinded review of medical records. Injuries were classified

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according to severity. Results: During follow-up, 118 (67%) of the participants fell 473 times
in total. At the interim 6-month follow-up, the incidence rate was 2.7 and 2.8 falls per person-
year in exercise and control group, respectively, and at 12-month follow-up 3.0 and 3.2 falls
per person-year, respectively. Negative binomial regression analyses indicated no difference
in fall rate between groups at 6 or 12 months (incidence rate ratio 0.9, 95% confidence
interval (CI) 0.5e1.7, P ¼ .838 and incidence rate ratio 0.9, 95% CI 0.5e1.6, P ¼ .782,
respectively). No differences in exercise effects were found according to sex, dementia type,
or improvement in balance. Participants in the exercise group were less likely to sustain
moderate/serious fall-related injuries at 12-month follow-up (odds ratio 0.31, 95% CI
0.10e0.94, P ¼ .039). Conclusions/Implications: In older people with dementia living in
nursing homes, a high-intensity functional exercise program alone did not prevent falls when
compared with an attention control group. In high-risk populations, in which multimorbidity
and polypharmacy are common, a multifactorial fallprevention approach may be required.
Encouraging effects on fall-related injuries were observed, which merits future investigations.

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Burton, E., Cavalheri, V., Adams, R., Browne, C.O., Bovery-Spencer, P., Fenton, A.M.,
Campbell, B.W. & Hill, K.D., 2015, ‘Effectiveness of exercise programs to reduce falls in
older people with dementia living in the community: a systematic review and meta-analysis’,
Clinical interventions in aging, vol. 10, p.421.
Objective: The objective of this systematic review and meta-analysis is to evaluate the
effectiveness of exercise programs to reduce falls in older people with dementia who are
living in the community. Method: Peer-reviewed articles (randomized controlled trials
[RCTs] and quasi-experimental trials) published in English between January 2000 and
February 2014, retrieved from six electronic databases – Medline (ProQuest), CINAHL,
PubMed, PsycInfo, EMBASE and Scopus – according to predefined inclusion criteria were
included. Where possible, results were pooled and meta-analysis was conducted. Results:
Four articles (three RCT and one single-group pre- and post-test pilot study) were included.
The study quality of the three RCTs was high; however, measurement outcomes,
interventions, and follow-up time periods differed across studies. On completion of the
intervention period, the mean number of falls was lower in the exercise group compared to
the control group (mean difference [MD] [95% confidence interval {CI}] =-1.06 [-1.67 to -
0.46] falls). Importantly, the exercise intervention reduced the risk of being a faller by 32%
(risk ratio [95% CI] =0.68 [0.55–0.85]). Only two other outcomes were reported in two or
more of the studies (step test and physiological profile assessment). No between-group
differences were observed in the results of the step test (number of steps) (MD [95% CI]
=0.51 [-1.77 to 2.78]) or the physiological profile assessment (MD [95% CI] =-0.10 [-0.62 to
0.42]). Conclusion: Findings from this review suggest that an exercise program may
potentially assist in preventing falls of older people with dementia living in the community.
However, further research is needed with studies using larger sample sizes, standardized
measurement outcomes, and longer follow-up periods, to inform evidence-based

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recommendations. Keywords: cognitive impairment, older people, physical activity, fallers,
community dwelling

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Hamed, A., Bohm, S., Mersmann, F. & Arampatzis, A., 2018, ‘Follow-up efficacy of
physical exercise interventions on fall incidence and fall risk in healthy older adults: a
systematic review and meta-analysis’, Sports medicine-open, vol. 4, no. 1, p.56.
Abstract
Background: The risk of falling and associated injuries increases with age. Therefore, the
prevention of falls is a key priority in geriatrics and is particularly based on physical
exercising, aiming to improve the age-related decline in motor performance, which is crucial
in response to postural threats. Although the benefits and specifications of effective exercise
programs have been well documented in pre-post design studies, that is during the treatment,
the definitive retention and transfer of these fall-related exercise benefits to the daily life fall
risk during follow-up periods remains largely unclear. Accordingly, this meta-analysis
investigates the efficacy of exercise interventions on the follow-up risk of falling. Methods: A
systematic database search was conducted. A study was considered eligible if it examined the
number of falls (fall rate) and fallers (fall risk) of healthy older adults (≥ 65 years) during a
follow-up period after participating in a randomized controlled physical exercise intervention.
The pooled estimates of the fall rate and fall risk ratios were calculated using a random-
effects meta-analysis. Furthermore, the methodological quality and the risk of bias were
assessed.
Results: Twenty-six studies with 31 different intervention groups were included (4739
participants). The number of falls was significantly (p