Assess the Effect of Exercises program on balance and prevention of recurrent falling among Elderly People

Introduction

Population ageing is widespread phenomenon across the world. According to the U.S. Census Bureau, the proportion of adults ages 65 years and older is projected to grow from 15 % in 2015 to 24 % of the population in 2060. (He, 2016). Also, Egypt is expected to have the largest number of old (23.7 million) and oldest old (3.1 million) populations in the region in 2050.(Sweed, 2016).

Age-related reduction in muscle mass (sarcopenia) and strength is associated with muscle weakness and physical disability. Maintaining an optimal level of muscle mass and muscle strength (balance) is necessary to prevent falls and disability throughout a lifetime.

Falls are defined as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest (on) furniture, walls or other objects” (Ambrose, et al., 2013).

Falls are the leading causes of death in elderly persons. Falls are responsible for 20%–30% of injuries among the elderly age group. They are also responsible for 50% of injury-related hospitalization among people of 65 years and above. (Sirohi, et al., 2017).Falls can also associated with reduced physical activity, deconditioning, functional decline, impaired ability to perform daily activities, social isolation, reduced quality of life, depression, increased risk of subsequent falls, and institutionalization. (Clemson, et al., 2019).

Evidence studies identified that balance training exercises as well as stretching exercises are more effective preventing falls and the percent of dependent elderly decreased.( Liu, & Fielding, 2011).

Exercise for older people canincreases balance, which may reduce the risk of falls or reduce the severity of a fall. Improves body composition (decreases fat, increases muscle mass). Decreases risk of injury and enhances immune function, and increases mobility and gait. (Physical Activity Guidelines Advisory Committee Scientific Report, 2018)

Gerontological nurse play an essential role in reducing falling and its related injuries through providing safety measures, environmental modification, eliminating risk factors and improving the balance through exercise training. (Morilla, et al.,2016).

Significance of the study

Falls are the second leading cause of mortality worldwide, and it is estimated that 80% of the falls occurring in low- and middle-income countries, of which South East Asia account for 60% of fall-related mortalities.(Joseph, Kumar, & Bagavandas, 2019).

In Egypt, according to the Central Agency for Public Mobilization and Statistics (CAPMAS) nearly 55% of the accidents occurring to the residents of the elderly homes resulted from falling and fractures Central Agency for Public Mobilization and Statistics. Arab Republic of Egypt. (Khodeir, & Abdelsalam, 2016).

Aim of the study:

Assess the effect of Exercises program on balance and prevention of recurrent falling among Elderly People.

Research hypothesis

To fulfill the aim of the study, It was hypothesized that the elderly people after performing exercises training program, will be decrease risk for falling and improve balance among elderly people.

Subjects and Methods

Research design

Quasi-experimental research design was utilized in the current study.

Subjects:

Purposive sample of 80 elderly clients male and female were collected through one year.

Inclusion criteria:

• Patients 60 years and older of both sex.
• Able to make exercises and perform Activity of daily living and balance.

Exclusion criteria:-

• Illiterate clients
• Bedridden elderly.
• Severely limiting arthritis.
• Severe psychiatric diseases
• Elderly have any health disorders are contraindicated for performing exercise.
• Elderly have any health disorders are affect the balance and movement.

Setting:-

The current study was carried out at three geriatric homes in minia city (Dar Omar Bn El khatab- Dar El Qedesa Hena- Dar El raee el saleh).

Study Duration:

The current study was conducted over aperiod of one year starting from August 2017 to August 2018.

Tools of data collection: - Two tools were used:

Tool I: Patient interview structured questionnaire. It covered two main parts:

• Part I;  Socio- demographic data of the elderly which included   (age, gender, level of education, and phone number.)
• Part II; Health history data included: medical history, presence of chronic diseases and medication used, and falling frequency.
• Part III; Data of client's knowledge about risk factor of falling, falling frequency, Define the word of falling, physiological changes lead to falling, Risk factor for falling (internal & external),What is the different kinds of sports can do it?,  benefits of exercises, preventive measures before, during and after exercises, consequences of falling, environmental safety to prevent falling.

Scoring system: each item was observed, categorized, and scored into either done =1 or not done= 0 on all items of the checklist. These scores are further classified as unsatisfactory level (less than 60%), and satisfactory level more than 60%).

Tool II:: Berg balance scale (BBS):

Berg Balance scale was used to assess the balance of elderly persons (Berg and Woo-Daphine, 1995). This scale was used pre and post performing exercises. It consists of 14 items graded 0 - 4 scale, which includes: sitting to standing, standing unsupported, sitting with back unsupported but feet supported on floor, standing to sitting, transfers, standing unsupported with eyes closed, standing unsupported with feet together, reaching in foreword with outstretched arm while standing, pick up object from the floor on standing position, turning to look behind over left and right shoulders while standing, turning 360 degree, placing alternate foot on  step or stool while standing unsupported,  standing unsupported in one foot on front, standing on one leg.

The total score is 56 and categorized as follows.

• 0 – 20    high fall risk.
• 21 – 40   medium fall risk.
• 41 - 56   low fall risk.

Tools validity:-

Content validity was done to identify the degree to which the used tools measure what was supposed to be measured. The developed tools were examined by a panel of five experts opinion in the field of the study {Minia University - faculty of nursing (Medical Surgical Nursing Department)} All jury members (100%) agreed that current study tools were valid and relevant with the aim of the study.

Tools reliability:-

Cronback's Alpha test was performed to check the stability of the internal consistency of instruments.

Pilot study:-

A pilot study was carried out on 10% (n = 8)   of the total sample to test the clarity of tools and estimate the time required for fulfilling it. Based on results of the pilot study no modifications or refinements were done and the subjects included to the actual sample.

Ethical Considerations:-

An official permission to conduct the study was obtained from the Ethical committee in the Faculty of Nursing, and agreement from Egypt academic for research center and technology. to carry out this study. Subject's participation   in this study was voluntary and each involved subject was informed about the purpose, procedure, benefits, and nature of the study, and that he/she had the right to withdraw from the study at any time without any rationale, then written consents were obtained. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data.

Procedure (Techniques for Data Collection):

The current study was conducted by preparing of different data collection tools, in addition to, obtaining formal paper agreement which was taken in duration one week before conducting the current study. The current study was conducted over aperiod of one year starting from August 2017 to August 2018. Then the researcher conduct the first interview with the elderly clients, and demonstrate with clients and care giver  about ( Definition of falls, incidence of falls., risk factors of falls, side effect of medication, the importance of follow up, consequences of falls, the environmental safety, and the benefits of exercises.

And after that the researcher conducts the research tools:

• Tool I: (1^st ,2^nd ,3^rd ) part Was applied before starting the exercise program. And 3^rd part was applied once after starting intervention.
• Berg balance scale (BBS), was applied before starting the exercise application, and after that was applied 6 times, once per month. (Berg, Woo-Daphine, 1995). And then was applied 3 times, once every two monthes.
• The researcher train the different exercises for each client (individualized sessions) 2 times weekly and train the caregiver to perform the exercise with the elderly clients. The clients were demonstrated and redemonstrated the exercises infront of the researcher to ensure the well performance.
• The duration of exercise was taken about 30-45 minutes and according to the ability of each client.
• The researcher was stopped the exercise when:
  • Occurrence of pain, discomfort in the chest, neck, jaw, arms.
  • Dizziness or syncope.
  • Ask the researcher to stop the exercises.
  • Palpitations or tachycardia.
  • Balance exercises include:
    • Sideways walking exercise was repeated 5 times.
    • Simple grapevine exercise was repeated 5 times.
    • Heel to toe walk exercise was repeated 5 times.
    • Step up exercise was repeated 5 times.
    • Sit to stand exercise was repeated 5 times.
    • Each session included the balance exercises. exercises will take about 30-45 minutes.
    • The client performs exercises 2 times weekly for 12 months.
    • The researcher follows the clients once weekly to evaluate the performance of exercise for the clients and caregiver.
    • The researcher design booklet in Arabic language, including exercises to improve the balance of elderly people. It was given to each elderly to guide and enrich his/her memory about activities performed in each session. The researcher gives instruction about the exercise to elderly and caregiver in geriatric homes.
    • The session plan was designed according to physical ability and attention span. The exercises will be performing according to checklist.

Statistical analysis of data:

Statistical analysis was done by using Statistical Package for the Social Science (SPSS 20.0). Quality control was done at the stages of coding and data entry. Data were presented by using descriptive statistics in the form of frequencies and percentage for qualitative variables, and mean & standard deviation (SD) for quantitative variable. Chi square was used to test the association between two qualitative variables and the sample size large. Fisher's exact test used to test the association between two qualitative variables   and the sample size is small. Graphs were done for data visualization using Microsoft Excel. Correlation coefficient test was also used between two variables and statistical significance was considered at p ≤ 0.05.

Result

Table (1): Distribution Percentage of Study Regarding to Socio-demographic Data (n=80)

Table (1): Reveals distribution of the studied clients according to the Socio-demographic data. The table show that (87.5%) of the study group between (60:>75 years), Regarding to gender it was found that (61.25%) were male, In relation to education levels it was found that (46.25%) of study group were have basic education, While (20%) of study sample have Bachelor degree.

Table (2): Distribution Percentage of Study Group Regarding to Medical Data     (n = 80)

Have you ever fallen in the last year?

Table (2) Shows that (55.5%) of study group were haven'tchronic illness,while(27.5%) of them were having hypertension, and only (12.5%) of the elderly having Hypertension & Diabetes, regarding to medication used it was found that (60%) of the study group were not used any medication. And in the last it was found that themost of sample (57.5 %) fall one time in the last year.  

Table (3)(A): Distribution Percentage of Study Group Regarding to Knowledge about Falling before and after Intervention (n = 80) (cont.)

Do you know the meaning of the word fall?

Fall of the elderly on the ground or fall on less than the level accompanied by loss or lack of awareness with the injury

Do you know the physiological changes associated with aging leading to the fall?

Changes in the motor system

Decreased the strength of sight

Decreased bone density

The three above

O.C (out of comparison)               t (paired sample t test)     ** highly Statistical significant (P ≤ 0.01)

Table (3)(A): Show that there was a highly Statistical significant differences in knowledge of elderly pre & post implementation that (70%) from study group define of falling incomplete definition, but (65%) of them select the two above after giving knowledge .The table also revealed that (45%)of  elderly know that decreased  bone density as physiological changes that leading to fall but after giving knowledge, but  (75%) of them select the three above that mean improvement of their knowledge.

Table (3)(B):Distribution Percentage of Study Group Regarding to Knowledge about Falling before and after Intervention (n= 80)(cont.)

Do you know the risk factors that lead to fall?

External Factors

Take a large number of medications

Urgency

The presence of diseases may affect the balance and movement

Weak arm muscle and leg

t (paired sample t test)                                         ** highly Statistical significant (P ≤ 0.01)

Table(3)(B):Shows that (27.5%) of clients didn’t know the external risk factors that lead to fall before intervention, (62.5%) from study group their answer were right (All of previous) of external risk factors of falling after intervention. And also (65%) of elderly after intervention their answer were right about internal risk factors of falling.(65%) from study group answer the question of complications as (Fracture anywhere in the body) but (68.75%) of them select the right answer (All of previous) after intervention.

Table (3)(C):Distribution Percentage of Study Group Regarding to Knowledge about Exercise needed before and after Intervention (n = 80)

t (paired sample t test)                                         ** highly Statistical significant (P ≤ 0.01)

Table (3)(C): show that (75%) of elderly clients before intervention know that only walking as a kind of sports they can do, but after intervention (75%) of them select the right answer (All of previous). And the table, also revealed that (72.5%) of study group had improvement in the point of what reserves should be observed before, during exercises and select correct answer (All the previous). Also (75%, 61.25%) respectively of study group had improvement in knowledge about benefits of exercises and the precautions to prevent falling with highly Statistical significant differences between the elderly knowledge before and after the intervention.

Table (4): Distribution of Study Group Regarding total Knowledge about Falling and exercises before and after Intervention (n = 80)

Paired samples t-test                   ** highly Statistical significant difference (P ≤ 0.01)

Table (4): Show highly Statistical significant differences regarding satisfaction of elderly knowledge before and after the intervention.

Table (5): Comparison between mean & SD 1st and last observation of Study Group Regarding to Berg balance scale (BBS) (n = 80)

       t (paired sample t test)                                                    ** highly Statistical significant (P ≤ 0.01)

        Table (5): Shows that highly Statistical significant (P ≤ 0.01) in difference between first and last observation in (BBS), that revealed improvement of Low risk of falling from (15%) in first observation to (80%) in last observation and decreased level of High fall risk from (50%) to (0%) in last observation, and also show ( t ) test value was (8.49)

Figure (1): Distribution of mean & SD throughout the 10 observations of Study Group Regarding to Berg balance scale (BBS) (n = 80)

Fig.(1): shows that highly Statistical significant difference between the mean and SD of 1st and last observation at (P ≤ 0.01).

Table (5): Correlation between Socio-demographic and Clinical Data regard to Berg Scale Score before and after exercise program (n=80)

     * Statistical significant difference (P ≤ 0.05)    ** highly Statistical significant difference (P ≤ 0.01)

Table (5) Illustrated a weak negative correlation between (age and medication used) and Berg Scale Score before and after intervention, documented by r value (r= -0.062 & -0.131), (-0.312 & -0.225)  respectively. On the other hand, there were positive correlation between male gender and Berg Scale Score after intervention among the study group, documented by r value (0.408). Moreover, there were a positive correlation between level of education and Berg Scale Score before and after intervention among study groups, documented by r value (0.046 & 0.333) respectively. While, there was a highly statistical significant positive correlation between (level of education) and Berg Scale Score after intervention documented by p value (0.005) respectively.