Exercise and caution work well in fight against falls
Question: As part of our falls prevention program, we’re considering more exercise programs for patients at risk for falls, to help them develop stability and balance. But we’ve heard some concerns that the at-risk patient is better off in bed instead of doing something that could result in a fall. What should we do?
Answer: You’ve stumbled upon one of the great dilemmas in dealing with patients at risk for falls, says Laurence Rubenstein, MD, MPH, professor of geriatrics at the University of California, Los Angeles and director of geriatrics research center at the Greater Los Angeles Veterans Administration Medical Center. "There’s your Catch-22," he says. "If you don’t encourage them to exercise they get weaker and become more of a fall risk. But if they’re up and exercising, they might fall."
The solution, Rubenstein says, is to carefully weigh the risks of a fall vs. the potential benefits for the patient. There will be some patients who clearly belong on one side of the issue or the other, but many more will fall somewhere in the middle and you will have to rely on clinicians to make a judgment call.
Exercise and acceptable risk
Rubenstein does encourage you to use exercise programs for those who can participate with an acceptable level of risk. Simply declaring that all patients at risk for falls should stay in bed instead of exercising is a poor solution, he says. "Then they may not be such a fall risk but they’ve lost their independence and quality of life," he says. "Life involves risks, and we have to accept that to some degree. The only way to completely eliminate the risk of falls is to immobilize people, and then you get risks of other things like blood clots, deconditioning, and pressure sores."
Exercise can be beneficial in reducing falls, mainly by improving strength and balance. But those who could benefit the most are at the highest risk for that very reason. So the exercise has to selected carefully for that group and done with supervision.
The only absolute answer to the question, Rubenstein says, is that you should not attempt an exercise program for patients at risk for falls if you don’t have enough staff to supervise them. A properly designed exercise program will require a lot of staff time, particularly for those patients who are in the initial phases of the program when their mobility is not clearly stable. "If you have limited staff, you should be focusing on the people who have a chance for continuing on their own once they get going, and that is usually the more cognitively intact population," he says. "Demented patients who are ambulatory probably should be considered higher risk and lower ultimate benefit. They probably won’t retain the experience long enough to benefit without constant supervision."
Rubenstein notes that, even if you have plenty of staff, you should not count on an exercise program having dramatic results on falls. While most of the studies related to exercise in hospitalized patients have shown beneficial results, he says those benefits often involve quality of life issues and not necessarily fall reduction. That is another reason to be careful about who you include in such a program and not to push too hard to include those patients who are most likely to fall during exercise. "I think exercise, when properly done, can help you reduce falls among this population and that the effort is worthwhile," he says. "But from a research standpoint, there is not enough reliable evidence to make promises about how much you’re going to reduce falls."
As part of our falls prevention program, were considering more exercise programs for patients at risk for falls, to help them develop stability and balance. But weve heard some concerns that the at-risk patient is better off in bed instead of doing something that could result in a fall. What should we do?
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