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Written by Jesse Muijsenberg
A seemingly simple fall in eldery, is not as simple as we might think. The length of admission to the hospital of elderly who fall is long and the mortality in the period after these falls is extremely high. Together with the fact that elderly fall often, we are talking about a serious number of events. Around 33% of the elderly experience an annual fall and 5-10% of this population suffers a severe fracture with sometimes even death as result. Is cognitive-physical dual task training a way to prevent elderly from falling and thereby reducing the public health problem that this population causes?
Due to the ageing population, elderly who fall are an increasing public health problem. In the United States the rate of deaths following a fall in elderly increased with 31% between 2007 and 2016. Broadly there are two main groups of factors that cause falling in the elderly population. The first group being environmental/extrinsic factors and the second group being intrinsic factors. Environmental factors include in-home organization, access to elderly care facilities, outdoor environment, use of medication etcetera. Intrisic factors include age, muscle weakness, gait and balance disorders, cognitive impairment and other diseases. It is often a combination of multiple factors that are at the root of a fall. It is important to early identify individuals at risk of falling and tackle the factors that will cause them to fall. When zooming in on the intrinsic factors, in the past decades less research was conducted investigating cognitive risk factors compared to research investigating physical risk factors. Nowadays cognitive factors are recognised as contributing factors for a higher fall risk. Specifically executive dysfunction is seen as the cognitive domain that predicts falls among elderly. The role of the executive domain is mainly adjusting to changing stimuli. Some examples of these changing stimuli during walking are barriers, a change gradient or uneven tiles. It is found that this ability to dual-task reflects the ability of our executive functioning. Then the question arises if it is possible to reduce the risk of falling in elderly by giving them cognitive-physical dual task training?
An earlier article ‘Combination Training, Twice As Good?” already highlighted some beneficial effects of dual-training on motor function. In this earlier article it is explained what a combination task actually means and how everyone in daily life comes across a huge amount of ‘dual tasks’. A literature search showed that several clinical trials and reviews have been performed investigating whether cognitive-physical training reduces the risk of falling in elderly. In this article we will highlight some of these articles.
Phirom et al. assessed the effect of interactive physical-cognitive game based training on the fall risk in elderly. They included 40 participants and divided them into two groups, the intervention and control group. The intervention group received 12 weeks of game-based dual-task training 3 times per week for 1 hour. They used the physiological profile assessment (PPA) and the timed up and go test to quantify fall risk. After the intervention period the control group took much longer to perform the timed up and go task than the intervention group. Also, the improvement in PPA score indicated a beneficial effect of this type of training on fall risk in elderly. Besides the decrease in fall risk, the game based dual task training had a beneficial effect on cognitive performance.
Piech et al. conducted a systematic review to determine whether virtual reality and exergames reduce the risk of falling among elderly. Exergames are game- and technology driven exercises. This article about the effect of exergames included 21 articles involving a total of 1557 patients. They assessed the physical performance, cognitive performance and among a few other outcomes the quality of life of the patients. They conclude that this way of training is a promising complementation or even a promising alternative to traditional training methods used by physiotherapists. It even seems that these kind of training methods offer greater effectiveness over the traditional training for physical functioning. Additionally in most of the reviewed studies the training significantly improved various cognitive functions as well as the quality of life and the risk of falling in elderly.
Spano et al. assessed whether simultaneous motor-cognitive training is more effective than sequential motor-cognitive training. 26 patients were randomly assigned to either the sequential motor and cognitive training group (MixT) or the simultaneously motor-cognitive training group (DTT). The population consisted of elderly diagnosed with cerebrovascular diseases. The results were very positive for the DTT group. There was a significant beneficial effect of the DTT-training for several cognitive- and physical tests pre- to post-intervention. The MixT group also shows an increase in performance post-intervention, however not of the same extent as the DTT group.
These 3 highlighted articles are definitely not the only articles showing a beneficial effect of cognitive-physical dual task training. It is concluded that a lot of evidence is showing that dual-task motor and cognitive training is a very promising training method to reduce the risk of falling in elderly. These articles and other articles learn us that cognitive training itself has beneficial effects, but cognitive- and motor dual task training is even more promising to prevent elderly from falling and contributes to reducing the public health problem. Lastly, a training-tool makes it easier to train in a dual-task matter and if needed standardize training methods.
References
- Coutinho, E.S.F., Block, K.V., Coeli, C.M. (2012). One-year mortality among elderly people after hospitalization duet o fall-related fractures: comparison with a control group of matched elderly. Cad Saude Publica. 28(4): 801-805
- Bergeron, E., Clement, J., Lavoie, A., Ratte, S., Bamvita, JM, Aumont, F., Clas, D. (2006). A simple fall in the elderly: not so simple. The journal of trauma: injury, infeciton, and critical care. 60(2): 268-273.
- Nickens, H. (1985). Intrinsic factors in falling among the elderly. Arch Intern Med. 145 (6): 1089-1093.
- Burns, E., Kakara, R. (2018). Deaths from falls among persons aged > 65 years – United States, 2007-2016. Morbidity and mortality weekly report. 67(18): 509-514.
- Valipoor, S., Pati, D., Kazem-Zadeh, M., Mihandoust, S., Mohammadigorji, S. (2019). Falls in older adults: a systematic review of literatur on interior-scale elements of the built environment. Journal of ageing and environment. 34(3): 1-24.
- Bergland, A. (2012). Fall risk factors in community dwelling elderly people. Norsk Epidemiologi. 22(2).
- Wright, S.L., Kay, R.E., Avery, E.T., Giordani, B., Alexander, N.B. (2011). The impact of depression on dual tasking among patients with high fall risk. Journal Geriatric psychiatry neurology. 2493): 143-150.
- Phirom, K., Kamnardsiri, T., Sungkarat, S. (2020). Beneficial effects of interactive physical-cognitive game-based training on fall risk and cognitive performance of older adults. Int j environ res public health. 17(17):6079.
- Piech, J., Czernicki, K. (2021). Virtual reality rehabilitation and exergames – physical and psychological impact on fall prevention among the elderly – a literature review. Applied science. 11:4098.
