Physical Therapy Exercises for Elderly at Home: What to Do?

Why do elderly people often fall?

With advancing age, our balance capabilities decrease, making us more prone to falls. We will explore:

• the changes in our bodies and environments that lead to a higher risk of falls;
• the risk factors for falls in the elderly;
• whether it is relevant to assess the risk of falls to better prevent them and, if so, how.

Physiological and Environmental Changes with Age

Even without any pathology, changes occur in our bodies and environments as we age.

Of course, there is significant individual variability: some people will age physiologically faster than others, for genetic reasons or based on behaviors they have adopted or the environment in which they have evolved.

Others, on the contrary, change much more slowly.

Physiological “aging” (or simply “change”) affects everything that makes up our bodies:

• our cells;
• our genes;
• our tissues (skin, bones, etc.);
• our molecules.

You can find a lot of information on this topic in French in any human physiology book or on many websites. Simply enter keywords into your search engine, such as “aging physiology” or “aging pathophysiology.”

Here are some examples of physiological changes that could potentially impact the risk of falls:

• our metabolism changes. We lose lean mass (bones, muscles, organs) and gain fat mass; our sleep is altered (less quantity, lower quality, more wake-ups);
• our vision decreases;
• our proprioceptive sensitivity decreases. The sensors all over our bodies that trigger reflexes to avoid falling become less competent;
• our respiratory capacity decreases.

These changes may begin for some individuals between the ages of 20 and 40 and become more significant as they age. Of course, there are considerable differences between individuals!

Risk Factors for Falls in the Elderly

Several studies seek what are called risk factors for falls.

Some of these factors are intrinsic: specific to the individual. They are more common in people who, all else being equal, fall. However, this does not necessarily mean that they directly cause the falls.

That’s why, even by addressing them, it’s not certain that the risk of falls will be significantly reduced.

These studies show, for example, that individuals over 60 are more likely to fall if they have (Jehu 2021):

👁️ poorer vision;
🧠 cognitive problems (memory, attention disorders, etc.);
🙄 fallen in the past year;
🧑🏻‍🦯 a slower walking speed (less than 0.6 meters/second);
💊 more than 4 medications, or psychotropic medications;
🫀 orthostatic hypotension (blood pressure drops) (Mol 2019).

Additionally, there are extrinsic risk factors related to the environment:

• inadequate housing;
• sedentary lifestyle, less active life.

Assessing the risk of falls in the elderly

How to determine if an elderly person is at a higher risk of falls than the average?

One can start by examining if they have identified risk factors. There are also tests or scales that doctors or physiotherapists can administer. The most common ones in France include:

• the Tinetti test;
• the Timed Up and Go test;
• the Berg Balance Scale;
• the measurement of walking speed over 10 meters;
• the Chair Stand Test; the Stratify / Saint Thomas scale (especially in rehabilitation).

No single test stands out. Research teams recommend using at least 2 to obtain a more nuanced overview of the risk of falls (Park 2018).

Some physical therapists or doctors may also simply test the person’s single-leg balance: can they maintain balance on one leg for more than 10 seconds without support? It’s an extremely simple and quick test to implement, and its reliability has also been tested.

As always in medicine/rehabilitation, it’s good to consider what actions will be taken based on the test results before using them.

Testing for the sake of testing is not particularly useful (except sometimes to satisfy the need to “do something”).

For example, based on the test results, will different measures be implemented? In most cases, I find the use of tests unnecessary. I only resort to them in specific contexts:

• to request ongoing care in a follow-up and rehabilitation unit or day hospital;
• to provide information to a family or a professional who has expressed a genuine desire to quantify the evolution of their relative’s or patient’s balance.

Several risk factors for falls have been identified in the elderly. It is sometimes possible to act on these factors to reduce the frequency of falls.

Fall prevention through exercise for elderly individuals living in non-medicalized environments

It is easier to conduct studies on people living in collective settings. That’s why there are more studies on fall prevention in such individuals. We will therefore review these studies initially. We can draw lessons from them, including for individuals living at home.

What types of people are concerned?

Several dozen studies on the effect of exercise on falls have been conducted on individuals over 65 years old living in so-called community places.

These places include assisted living facilities or senior residences, both in the private and public sectors. These are places where facilities and services are adapted for the elderly or those with reduced mobility. However, these are non-medicalized environments.

Medical or paramedical staff may come occasionally but are not permanently present on the premises. Therefore, individuals residing in such places maintain a certain level of autonomy.

Numerous studies have been conducted on this type of population to find interventions that can reduce their risk of falling.

Among them, 108 studies compared the effect of regular physical exercise to the absence of such practice. These studies were conducted in 25 countries with more than 20,000 participants.

The participants had an average age of 76, and 77% were women. They were either at risk of falling or not.

Heart failure is not a contraindication to physical exercise. Individuals who have fallen before and had a femur fracture can also benefit from rehabilitation sessions to reduce the risk of another fall; this is referred to as secondary prevention.

The same applies after a fall that resulted in, for example:

• a wrist fracture;
• a trochanteric fracture;
• a patellar fracture;
• an elbow fracture.

Physical therapists may identify the person’s fall factors. Here are some of them:

• an inadequately adapted walking aid;
• a slippery floor or one covered with rugs;
• suboptimal furniture and bathroom layout;
• orthostatic hypotension;
• positional vertigo.

What exercises to perform?

Are all types of exercises interesting for preventing falls? For example, does walking have the same effect as performing specific balance exercises?

These studies suggest that, for fall prevention, it is better to:

• do various types of exercises;
• do balance exercises (with or without equipment; Tai Chi can be considered an activity involving balance, as well as Pilates or yoga. It doesn’t matter what we call the activity!);
• do functional exercises (such as getting up several times from a chair);
• do resistance exercises (for example, pushing a weight with the foot while walking sideways).

Simply walking or dancing does not seem sufficient to prevent the risk of falls. Regarding the effects of sessions mainly composed of stretching or endurance exercises, there are no studies that provide information on their effects.

How often should exercises be performed?

The exercises conducted in the studies took place at least once a week for about 30 minutes to an hour, and sometimes up to three times or more. They were repeated over several weeks or months, often for at least 12 weeks.

Although there isn’t yet much data to determine the ideal frequency, it appears that the effects of physical exercises are better when performed three times a week rather than once a week.

Is it better to do these exercises alone or in a group?

There is not enough data to recommend either group or individual practice. In the absence of such data, the fall risk of the individuals targeted by the programs is a determining factor in choosing to do these sessions alone or in a group.

If the person is at high risk of falling, it is better for them to perform their exercises under supervision and individually to ensure their safety.

It is entirely possible that physical exercise has an effect even when done independently, without a physiotherapist or other professional guiding the exercises.

However, some individuals may need a professional to ensure their safety or to provide guidance and motivation.

Is the risk of falls truly reduced with exercise?

Physical exercise under the previously described conditions does indeed reduce the risk of falls in these individuals.

Specifically, it reduces the risk of falls over time by about a quarter compared to those not engaging in physical exercises. What does this mean concretely?

It means that if we randomly select 1,000 individuals over the age of 65 and follow them for a year:

• 850 falls will occur if they do not engage in physical exercises;
• 655 falls will occur if they engage in physical exercises, which is 1/4 less.

There are fewer falls in the groups of individuals practicing physical exercises, but also fewer individuals experiencing falls (whether they fall once or multiple times).

If 480 individuals experience one or more falls in a year, there will be 72 fewer in a group practicing these exercises.

Do exercises also have an effect on other parameters, such as the number of fractures or hospitalizations, the consumption of medical care, or overall quality of life?

There is less data regarding these other indicators. However, it seems that physical exercise also reduces the risk of fractures by about 1/4.

Exercises and physiotherapy can also decrease the fear of falling in individuals over the age of 65.

Are there any side effects when practicing exercises?

In studies, side effects related to the practice of physical exercise are sometimes noted. In the vast majority of cases, these are musculoskeletal pains or disorders without any seriousness.

Out of the 23,000 individuals, only 2 experienced more significant side effects: a secondary fracture and a herniated disc, both attributed to the practice of exercises.

Regularly practicing physical exercises helps limit the frequency of falls in elderly individuals living in non-medicalized collective living environments, with a low and deemed minor risk of side effects.

Prevention of falls through exercise in elderly individuals living at home

In elderly individuals living at home, programs involving physical exercises combined with education on fall prevention or home visits to assess safety are sometimes implemented.

Individuals benefiting from these programs probably experience fewer and less frequent falls, but those living at home are less studied than those in communal settings.

Again, it is better to prioritize physical exercises that engage strength, function, and balance than simply walking. However, this should be adapted on a case-by-case basis.

For example, some individuals (or their caregivers in cases of cognitive impairment) may primarily want to maintain outdoor walking abilities; in this case, walking assistance may be relevant.

In individuals with cancer (whether elderly or not), physical exercise can improve strength, flexibility, and balance, but there is still too little data to precisely know its effects. The only identified study did not show a decrease in the risk of falls.

In elderly individuals who have already fallen, rehabilitation for a post-fall syndrome is sometimes necessary.

Individuals with Parkinson’s disease can also benefit from physiotherapy, but on parameters other than the frequency of falls.

Regularly practiced exercises also limit the risk of falls in elderly individuals living at home.

See also: Fear of Falling While Walking Remedies

Prevention of Falls through Exercise in Nursing Homes, Retirement Homes, and Hospital Settings

There are also studies conducted specifically in these living environments. A Cochrane collaboration synthesis compiles around sixty studies on the subject, including more than 6000 individuals residing in nursing homes (Crocker 2013).

Physical exercises were administered by rehabilitation professionals (physiotherapists, occupational therapists).

Once again, there are good reasons to believe that physical exercise in nursing homes is beneficial in reducing the frequency of falls. However, not all residents can necessarily follow such exercises or may not wish to.

Should one attend physical therapy sessions for fall prevention?

Physicians regularly prescribe physical therapy sessions for fall prevention in the elderly.

In this context, it is often relevant to turn to physical therapists for fall risk prevention in the elderly.

Other professionals may have developed skills to supervise such exercises:

• Sports coaches
• Nurses
• Nursing assistants
• Home caregivers
• Occupational therapists

In most cases, their services are paid for (sometimes partially deductible from taxes).

Depending on your place of residence, some municipalities, healthcare facilities, or departments offer collective sessions of adapted physical activity for seniors, partly or entirely covered. Often in the form of workshops.

Check directly with them. This is also the case for some health insurance providers.

Some of these professionals, especially physiotherapists and occupational therapists, can also provide guidance for fall prevention beyond “simple” exercise supervision:

• Home modifications
• Monitoring orthostatic disorders
• Choosing the most suitable walking aid, etc.

Finally, some individuals are capable of performing relevant exercises by themselves. For example, by visiting fitness trails or even simply at home.

🔗 Read more: Home Physiotherapy for the Elderly

What Else Can Be Done for Fall Prevention Besides Exercises?

It is possible to address other factors to prevent falls. Here is a set of things that can be done by a home physiotherapist, an occupational therapist conducting a home visit, or more rarely, a doctor or physiotherapist from their office:

• Modify the living environment through simple measures (appropriate lighting, installation of handrails in hallways, toilets, or on the bed, securing or removing rugs, etc.).
• Correct certain vision problems (cataract surgery) or cardiac rhythm disorders (pacemaker implantation).
• Correct hypotension (a drop in blood pressure causing dizziness) by wearing compression stockings or socks, or by providing advice on getting up more slowly.
• Regularly and systematically review the usefulness of each medication in the prescription that may contribute to falls.
• Encourage regular physical activity, exposure to sunlight, sufficient calcium intake, and reduce tobacco, alcohol, and caffeine consumption.

⚠️ Taking vitamin D or calcium does not limit the occurrence of fractures in the event of a fall (JAMA 2019).

It is challenging to quantify and precisely evaluate the impact of each of these interventions taken individually or even all of these interventions together.

However, they are theoretically coherent, and several studies (Cochrane 2018) show that these interventions, combined with regular physical exercise, can reduce the frequency of falls (but not other parameters such as hospitalization frequency).

Modifying the living environment and reducing the risk of falls related to a blood pressure problem are among the other measures that physiotherapists can implement to prevent the risk of falling.

Summary: Fall Prevention through Exercise in the Elderly

Practicing physical exercises after the age of 65 reduces the risk of falling/falling often (but does not seem to impact other factors such as quality of life, fractures, hospitalizations).

It is better to prioritize balance exercises, functional exercises, and resistance exercises over pure physical activity (walking or dancing).

Ideally, practice these exercises 2 to 3 times a week for at least 30 minutes to 1 hour for a minimum of 3 months. In real life, do as much as you can; that’s already something!

Don’t feel like it? There’s no need to feel guilty, as the positive effects are weak or uncertain on a population scale even with very frequent practice.

Other measures can be implemented by physical therapists, occupational therapists, and doctors to prevent the risk of falling (home modifications, correction of orthostatic disorders, etc.).