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Dementia – Prevent frailty, falls and improve mobility

Prevent frailty, falls and improve mobility

Evidence summary

There is a large body of evidence from the general older adult community that promotes the benefits of physical for the prevention of falls and frailty.  The evidence base is weaker for individuals with established cognitive decline with moderate to severe impairment. Overall the recommendation is in favour of multicomponent interventions incorporating both physical and cognitive components, which demonstrate positive effects on balance, functional mobility and gait speed when compared with a control and had significantly better effect on balance and gait speed within mild cognitive impairment populations.

For individuals with established cognitive decline the expert recommendation is to seek support to deliver the intervention, either through group based exercise with charity and local community groups with experience working with clients with cognitive decline, or to seek expert support from physiotherapist, occupational therapies and physical activity professionals with experience working with individuals with cognitive decline.

Expert opinion recommends mixed activity types which includes resistance training, balance and flexibility and aerobic activity.

Quality of evidence

Mixed quality – strongest evidence is for populations recruited from the general older adult population.  The evidence is weaker in studies recruiting populations with established diagnosis and moderate to severe cognitive decline.

Strength of recommendation

Low – for individuals with established diagnosis of dementia

Strong – from expert opinion and based on wider literature from the older adult population.

Conclusion

Being physically active maintains muscles – through combined resistance and balance training – to prevent frailty and falls.

Selected references

Effect of Exercise and Cognitive Training on Falls and Fall-Related Factors in Older Adults With Mild Cognitive Impairment: A Systematic Review

Lipardo, Donald S. et al. October 2017

Archives of Physical Medicine and Rehabilitation , Volume 98 , Issue 10 , 2079 – 2096

Seventeen RCTs (1679 participants; mean age ± SD, 74.4±2.4y) were included.

  • Exercise improved gait speed and global cognitive function in MCI
  • Combined exercise and cognitive training improved balance in MCI.
  • Neither fall rate nor the number of fallers was reported in any of the studies included.

Interventions incorporating physical and cognitive elements to reduce falls risk in cognitively impaired older adults: a systematic review. Booth, Vicky; Hood, Victoria; Kearney, Fiona

JBI Database of Systematic Reviews and Implementation Reports: May 2016 – Volume 14 – Issue 5 – p 110–135

Eight RCTs were included

  • Effectiveness of multicomponent exercise programs, including physical and cognitive activities, music-based group exercise and mind-body tai chi on falls related outcomes.
  • Most of the studies were of good quality with an average quality score of 7.5. Four studies reported effectiveness based on the number of falls, half of which reported a significant difference between the groups.
  • Falls related outcomes that were combined in meta-analysis included balance (Berg balance scale), functional mobility (Timed Up and Go) and gait speed (m/s). There was a statistically significant improvement in balance and gait speed following the intervention; however, the studies were too heterogeneous to be included in the analysis from the functional mobility results.

Overall, multicomponent interventions incorporating both physical and cognitive components demonstrated positive effects on balance, functional mobility and gait speed when compared with a control and had significantly better effect on balance and gait speed within mild cognitive impairment populations.

Effects of physical exercise interventions in frail older adults: a systematic review of randomized controlled trials

Carmen de Labra et al, BMC Geriatrics 2015 15:154

Nine papers met the inclusion criteria.

Six included multi-component exercise interventions (aerobic and resistance training not coexisting in the intervention).

Five investigated the effects of exercise on falls, and among them, three found a positive impact of exercise interventions on this parameter. Six trials reported the effects of exercise training on several aspects of mobility, and among them, four showed enhancements in several measurements of this outcome. Three trials focused on the effects of exercise intervention on balance performance, and one demonstrated enhanced balance. Four trials investigated functional ability, and two showed positive results after the intervention. Seven trials investigated the effects of exercise intervention on muscle strength.

Exercise interventions have demonstrated improvement in different outcome measurements in frail older adults, however, there were large differences between studies with regard to effect sizes.

Review suggested that frail older adults seemed to benefit from exercise interventions, although the optimal program remains unclear.

Effect of Structured Physical Activity on Prevention of Major Mobility Disability in Older AdultsThe LIFE Study Randomized Clinical Trial. 

Pahor M, Guralnik JM, Ambrosius WT, et al.

JAMA. 2014;311(23):2387–2396. doi:10.1001/jama.2014.5616

The Lifestyle Interventions and Independence for Elders (LIFE) study was a multicenter, randomized trial, randomized a volunteer sample of 1635 sedentary men and women aged 70 to 89 years who had physical limitations, defined as a score on the Short Physical Performance Battery of 9 or below, but were able to walk 400 m.

Participants were randomized to a structured, moderate-intensity physical activity program (n = 818) conducted in a center (twice/wk) and at home (3-4 times/wk) that included aerobic, resistance, and flexibility training activities or to a health education program (n = 817) consisting of workshops on topics relevant to older adults and upper extremity stretching exercises.

The primary outcome was major mobility disability objectively defined by loss of ability to walk 400 m.

Incident major mobility disability occurred in 30.1% (246 participants) of the physical activity group and 35.5% (290 participants) of the health education group (hazard ratio [HR], 0.82 [95% CI, 0.69-0.98], P = .03).Persistent mobility disability was experienced by 120 participants (14.7%) in the physical activity group and 162 participants (19.8%) in the health education group (HR, 0.72 [95% CI, 0.57-0.91]; P = .006). Serious adverse events were reported by 404 participants (49.4%) in the physical activity group and 373 participants (45.7%) in the health education group (risk ratio, 1.08 [95% CI, 0.98-1.20]).

A structured, moderate-intensity physical activity program compared with a health education program reduced major mobility disability over 2.6 years among older adults at risk for disability. These findings suggest mobility benefit from such a program in vulnerable older adults.