The influence of frailty on the efficacy of exercise for falls prevention - A systematic review, meta-analysis and meta-regression

Purpose

· Update the evidence on the effect of exercise on fall rates

· Attribute levels of frailty and analyse with respect to exercise intervention effect measured by rate of falls

· Derive results for frailty sub groups and dichotomous frailty across the following populations;

o Community–dwelling

o Residential care

o Parkinson’s disease

o Stroke

o Cognitive impairment

o Recent hospital discharge

· Assess quality of the evidence

· Determine implications for clinical practice and further research

Approach

Systematic review with random-effects meta-analysis and meta-regression.

Outcomes

Results: Moderate quality of evidence demonstrates exercise is effective in reducing falls of non-frail older people living in the community, IRR 0.82 (95%CI 0.77-0.88). Moderate to very low quality evidence demonstrates frailty did not influence the efficacy of exercise for the prevention of falls. However frailty sub-groups 3 and 4 within the community dwelling population showed effective results. IRR of 0.82 (95%CI 0.72-0.93, I2 52.5%, p=0.001, 28 comparisons, N=8326) and 0.76 (95%CI 0.65-0.88, I2 59.2%, p=0.001, 18 comparisons, N=4990) respectively.

Conclusion(s): This review consisted of 27021 participants from 108 studies. Higher quality research is required to identify how best to prescribe exercise stratified by frailty to support clinical recommendations. Strengths

· First study of its kind to authors knowledge

· Preliminary evidence of non-linear relationship between exercise for falls prevention and frailty

· Main outcome has good content and criterion-related validity

· No publication bias identified in two largest sub-populations

Limitations

· No protocol published a priori

· No pilot data extraction conducted

· Sensitivity analysis may have yielded higher quality results

Cost and savings

No further information. 

Implications

In terms of evidence for exercise to reduce falls in older people this update of the 2017 Sherrington review increased the sample by a 1/3 and maintained an effective result for the community dwelling population and any reduction in Incidence Rate Ratio (IRR) can be considered clinically important. This assures the positive impact of services providing exercise programs in maintaining the health of the population and reducing the burden of falls on the NHS. In terms of the influence of frailty there is a hint in the results of a non-linear relationship between frailty and the influence of exercise on falls where those who are pre-frail respond better to the intervention than those who are non-frail or moderately frail and beyond. This gains construct validity from World Health Organisation’s threshold model of disability. Whilst acknowledging frailty is not exclusive to older people it would also be compatible with the National Institute for Health and Care Excellence guidance, Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset. Current primary care policy is at odds with this however as referral to exercise for falls or frailty services require a moderate to severe frailty diagnosis

Top three learning points

No further information. 

Funding acknowledgements

Unfunded.