strength and balance for better health and wellbeing

Strength and Balance for Better Health and Wellbeing

January 2017Louise AnsariAideen Young

The Centre for Ageing Better received £50 million from the Big Lottery Fund in January 2015 in the form of

an endowment to enable it to identify what works in the ageing sector by bridging the gap between

research, evidence and practice.

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Declines in strength and balance with age


Strength (muscle and bone)• Loss of muscle mass per decade in adults aged 40─70 years1: 8%

• Loss of muscle mass per decade in adults aged 70+: 15%• Decrease in muscle strength per decade for someone in their 50’s and 60’s: 15%

• Decrease in muscle strength for someone aged 70+2: 30% • Proportion of people aged 85+ in the UK who suffer from sarcopenia (degenerative loss

of skeletal muscle mass quality and strength)3: 21%• Bones become more brittle with age, particularly for post-menopausal women

Balance• As we age, our balance and reaction times and reflexes get slower

• Proportion of adults 72+ who experience some form of dizziness4: 20-30%• Dizziness, caused by medical conditions or medications can also affect balance

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Impaired balance

Increased risk of falls

InjuriesFear of falling

Immobilisation

Loss of muscle mass (sarcopenia)

Reduced physical activity

Reduced energy levels

Reduced strength and

power


Age-related changes+medication or disease

Cycles of adverse outcomes

DisabilityDependency

InstitutionalizationDeath

Reduced bone

strength

Loss of muscle mass (sarcopenia)

Impaired balance

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Frailty, a syndrome related to the ageing process


• Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves1

• Frailty is a social care and healthcare challenge because it strongly predicts nursing home placement2

• Frailty is associated with an increased risk of3:

Difficulty staying upright, maintaining balance and walking, leading to disability

Inability to take part in activities necessary for daily life such as bathing

Leading to loss of memory, problems with language, thinking and judgment and delirium

The more vulnerable an individual is, the higher the risk of falls,immobility or disability, institutionalisation and death

PHYSICAL DECLINE FUNCTIONAL DECLINE COGNITIVE DECLINE

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Falls and fractures: the impact on people


• One-third of people aged 65+ and 50% of over-80’s living at home fall at least once a year1

• Over 60% of those living in nursing homes fall repeatedly2

• Around 70,000-75,000 hip fractures occur in the UK each year, mainly due to falls3

• Of those who experience hip fracture4: 24% return to their pre-fracture level of function

42% require extra help with day to day activities

21% require an increased level of residential or hospital care

35% receive increased community health and social service care at home†

• 1 month after hip fracture 1 in 12 people will have died and only half will have returned home6

• Falls reduce confidence, increase isolation and reduce independence, with around 1 in 10 older people who fall becoming afraid to leave their homes in case they fall again7

†At 90 days post-fracture)

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• Cost of fragility fractures: £2 billion per year2

• Increase in care home admissions due to falls by 20201: 17.7%

• Number of people in the UK who end up in A&E after a fall: 280,000; cost to the NHS: £1.5 billion1

• Number of hospital bed days each year in England because of falls and fractures in people aged 65+: 4 million2

Falls and fractures: the impact on services

†Physiotherapy and tailored physical exercise programmes


7Strength and Balance for Better Health and Wellbeing

• Specific, well-directed programmes that include strength and balance training†:

improve body balance and muscle structure in older people1

can reduce the risk of falls by up to 55%2

are beneficial both in terms of preventing and treating frailty3,4

resulted in a significant difference in the occurrence of frailty5

significantly improved knee joint pain among older adults6

has positive effects on risk factors for cardiovascular disorders, cancer, diabetes, and osteoporosis7-10

• In contrast, in healthy, active men and women, running alone was not sufficient to prevent the loss in muscle strength that occurs with ageing11

Effectiveness of strength and balance training

†either as a single intervention or as a component of multicomponent interventions

Falls and frailty can be prevented through strength and balance training

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Examples of exercise for strength and balance


Muscle strengthAny activity that requires your muscles to work harder than normal, e.g: •Sit to stand•Squats•Calf raises•Sideways leg lift•Leg extension•Bicep curls•Lifting weights•Chair dips•Resistance bands•Aqua aerobics1

•Pilates2

•Stair descending3

Bone strengthBest exercises for building and maintaining strong bones are weight-bearing and muscle-strengthening, e.g:

•Yoga•Walking•Running•Dancing

Balance

• Yoga4

• Tai chi5,6

• Pilates7

• Heel raises• Toe raises• Sit to stand• Heel to toe stand• Standing on one leg• Sideways walking• Step-up• Aqua aerobics1

• Elastic band resistance exercise8

• Swiss ball9

• Mini trampoline10

• Stationary bicycle11

• Tae Kwon Do12

Evidence-based multicomponent exercise programmes: Otago falls programme

Zumba Gold

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Chief Medical Officer’s guidelines (2011)

• Older adults should undertake physical activity to improve muscle strength on at least two days a week

• Older adults at risk of falls should incorporate physical activity to improve balance and coordination on at least two days a week

• Physical activities that strengthen muscles involve using body weight or working against a resistance. This should involve using all the major muscle groups. Examples include: Carrying or moving heavy loads such as groceries Activities that involve stepping and jumping

such as dancing Chair aerobics

• Activities to improve balance and co ordination ‑may include: Tai chi Yoga Pilates


From: Department of Health. UK physical activity guidelines. 2011

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Who does muscle-strengthening activities?

From: Health Survey for England - 2012


Proportion of men 55─64 years who meet the guidelines for muscle-strengthening activity: <20% Proportion of men and women, 75─84 years who meet the guidelines for muscle-strengthening

activity: 10% and 4%, respectively Even among people who meet guidelines for aerobic exercise, the proportion who meet

recommendations for exercise to improve balance and coordination (at least 2 days/week) is low

%

Men Women

Age group Age group

None<2 days/weekAt least 2 days/week (meets guidelines)

16-24 16-2425-34 25-3435-44 35-4445-54 45-5455-64 55-6465-74 65-7475-84 75-8485+ 85+0

20

40

60

80

100


In December 2016 Centre for Ageing Better commissioned an Ipsos Mori survey of 1084 respondents aged 40+ in Great Britain. This found that:

• 30-50% did not know that yoga and tai chi, heavy gardening and carrying heavy loads such as groceries can improve strength and balance

• 25% did not know that dancing can improve strength and balance

• 30% or more did not know that strength and balance exercises: Reduce blood pressure Improve sleep Increase bone strength and health Build muscle mass Reduce risk of falls But have no impact on the risk of Alzheimer’s disease

• 51% did not know that strength and balance exercises help relieve arthritis symptoms

• 94% thought that walking did improve strength and balance

Strength and balance exercises: misconceptions

Another common misconception is that walking is more effective than lifting weights for building muscle strength

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• Lack of awareness of the potential of strength and balance training to reduce falling risk (most people assume that falls prevention entails restricting activity and using aids1)

• Concerns about whether strength and balance training might be harmful, tiring or painful1

• Falls prevention measures incompatible with self-image as capable and independent2

• Whether or not the person, and their family, friends and doctor think that it is an appropriate activity for someone like themselves3

• Reasons that adults aged 65+ with impaired balance gave for not sticking to a home exercise programme following discharge from physical therapy 4

No interest Poor health Weather Depression Weakness Fear of falling Shortness of breath Low outcomes expectations


Personal barriers to strength and balance training

Barriers are more important than motivations in determining whether or not you stick to exercise4

The threat of falling may not be a compelling motivation for undertaking strength and balance exercise1


• Older people have limited access to evidence-based falls prevention programmes

• And where these programmes are available, the vast majority are altered or scaled down to an average duration of 12 weeks or less2 (whereas a ‘dose’ of at least 50 hours of a tailored exercise programme is necessary to reduce falls1)

• Falls prevention is often focussed on the secondary prevention of falls rather than preventing falls in the first place3

• Continued misconceptions about the evidence base

• Increased burden of health care costs

• Inadequate access to suitably trained staff4

• Instructors who are not properly trained5

System barriers to strength and balance training

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When to start strength and balance training?


• As with any form of exercise, strength and balance training should be commenced as early as possible in the life course and maintained for maximum benefit

• However, it is never too late to start and even much older people and people in poor health can benefit from exercise programmes: An 8-week balance exercise and elastic resistance exercise programme led to significant

improvements in muscle strength and balance in people aged 75+1

Exercise (including resistance training) had moderate-to-large benefits on inflammation, muscle strength and physical function in older people with frailty2

Resistance training increased upper and lower extremity muscle strength and maximum oxygen uptake and improved mobility in older people with coronary artery disease3

In older people with mild to moderate dementia, a 4-month, high-intensity exercise programme improved balance and slowed the decline in people’s ability to attend to daily self-care activities

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Action for individuals


• Greater public awareness of the importance of strength and balance

• Greater awareness and understanding of exercise to improve or safeguard strength and balance ̶ what it entails and what benefits it brings

• Modifying your own home to reduce falls risk, e.g. Ensure adequate lighting Fit baths and showers with handles Wear appropriate, well-fitting footwear

• Do more self-guided strength and balance exercise

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Action for health professionals


• More understanding of the health and physical activity needs of older people• Multifactorial risk assessment of older people during all encounters with health and

social care professionals with particular attention paid to people* with:

Low strength and power Multiple medication use Incontinence Cognitive impairment Depression

Vision or hearing loss Problems with foot care Poor housing Poor diet Stroke

• Treatment of medical conditions• Review of medication• Gait training and training on use of assistive devices• Home assessment and modification• Plus, commissioning of, and referral to, individually tailored strength and balance

programmes1

*Socially disadvantaged older adults or those living alone as well as those with chronic conditions or disabilities are at particular risk

Delirium Balance or gait disturbances Previous falls Fear of falling Functional incapacity

And following assessment, as required:

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Designing strength and balance services


Key elements in a whole system approach to the prevention of loss of muscle mass and strength and balance that lead to frailty and falls in older age are:

• Services that: Provide multifactorial risk assessment and timely and

evidence-based tailored interventions for those at high risk of sarcopenia or falls Provide evidence-based strength and balance programmes for those at low to moderate

risk of sarcopenia or falls Home hazard assessment and improvement programmes

• Sourcing providers

• Delivering to users

• Monitoring and evaluation of services

• Development of quality standards and guidance

• Appropriate governance frameworks

Promote healthy ageing across the life course

An emphasis on prevention, not treatment!

Designed in partnership with older people, their carers and families

Contact

Centre for Ageing Better Level 3, Angel Building407 St John StLondon EC1V 4AD020 3829 0113ageing-better.org.uk

Registered Company Number: 8838490 & Charity Registration Number: 1160741

Thank youLouise [email protected]

020 3862 9186

The Centre for Ageing Better received £50 million from the Big Lottery Fund in January 2015 in the form of

an endowment to enable it to identify what works in the ageing sector by bridging the gap between

research, evidence and practice.

strength and balance for better health and wellbeing

Government & Nonprofit