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Tai Chi and Geriatric Falls

Medical Report: Geriatric Falls and Tai Chi

Eric L. Zielinski

 

Introduction

 

Accidents are ranked number five on the top ten causes of death for people over 65 years of age. Of this group, 66 percent are due to falls making falls the leading cause of injury death for older Americans. In addition, it is reported that geriatric falls are the most common cause of nonfatal injuries and hospital admission for trauma. It is, therefore, a national public health requirement for health care professionals to address this issue with their older patients. It is encouraging that many have adopted “alternative” solutions like advising their patients to practice regular Tai Chi in an effort to curb the deadly ramifications of falling later in life. 

 

Geriatric Falls

 

Due to lack of reporting, no one knows for certain how many elderly people fall in America, however, it is estimated that the number is more than one in three annually. The Centers for Disease Control and Prevention (CDC) claims that in 2010, “2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized;” thus, accounting for $30.0 billion in related medical costs.

 

Common complications of falls contributing to this astounding figure include: 

 

    • Soft tissue injury – leading to muscle weakness and disability.
    • Fractures – hip, femur, humerus, wrist, ribs in this order.
    • Sub-dermal hematoma – hitting the head is not necessary as whiplash type head movements can cause localized blood-filled swelling in the head as geriatrics fall on their back or side.
    • Hospitalization subsequently leading to iatrogenesisa significantly common, preventable hazard of hospitalization and is associated with longer hospital stays, increased patient mortality and cost.
    • Disability – emotional, physical, mental (especially depression and fear).
    • Institutionalization – admittance to a nursing or convalescent home, etc.

 

  • Death

 

 

Independent of age, geriatric ‘risk factors” contribute the most to geriatric falls and are what needs to be addressed by health care professionals as they advise their patients. The following list is taken from the National Institute of Health NIH Senior Health:

 

  • Muscle weakness, especially in the legs. Believed to be one of the most important factors, older people with weak muscles are more likely to fall than are those who maintain their muscle strength, as well as their flexibility and endurance.
  • Balance and gait. Older adults who have poor balance or difficulty walking are more likely to fall than others. These problems may be linked to a lack of exercise or to a neurological cause, arthritis, or other medical conditions and their treatments.
  • Hypostatic hypertension. Blood pressure that drops too much when older adults get up from lying down or sitting can significantly increase the chances of falling. This condition can result from dehydration or certain medications. In addition, it is oftentimes linked to diabetes and neurological conditions such as Parkinson's disease, or an infection. 
  • Diminished reflexes. The increased amount of time it takes geriatrics to react makes it more difficult for them to correct a fall at the onset. 
  • Foot problems. Painful feet and wearing unsafe footwear increases the chance of falling. Backless shoes and slippers, high-heeled shoes, and shoes with smooth leather soles are examples of unsafe footwear that oftentimes cause a fall.
  • Sensory problems. If the senses don't work well, people are much less aware of their environment. For instance, having numbness in the feet will make people unaware of changes in their walking conditions such as steps, bumps, curbs, cracks or slippery areas.
  • Vision issues. One of the main conditions causing falls in geriatric patients is the prolonged amount of time required to accommodate to light and dark environments like from going into a movie theater to sunny day outside the building. Other vision problems contributing to falls include poor depth perception, cataracts, and glaucoma. Wearing multi-focal glasses while walking or having poor lighting around the home can also lead to falls.
  • Confusion and disorientation. For example, when people wake up in an unfamiliar environment, they might feel unsure of where they are. Subsequently, this confusion may cause someone to panic and/or take unsure steps as they get acclimated to their environment. When this happens, it is vital for people to wait a minute or two for their mind to clear or until someone comes to help before they try to get up and walk around.
  • Medications. Medications oftentimes cause side effects like dizziness and confusion. The health problems for which the person takes the medications may also contribute to the risk of falls.
  • The more medications you take the more likely you are to fall. People who take four or more prescription drugs have a greater risk of falling than do people who take fewer drugs. Geriatric patients need to check with their doctor if they think their medications are causing dizziness or unsteadiness. Hopefully, their doctor can determine which drugs, including over-the-counter medicines, might be causing the problem.

 

In summary, according to the National Institutes of Health, “Falls don't ‘just happen,’ and people don't fall because they get older…. Many falls are linked to a person's physical condition or a medical problem, such as a chronic disease. Other causes could be safety hazards in the person's home or community environment.”

Medical Research and Management

 

It is very promising to learn that the medical community has recently embraced Tai Chi and alternative therapies to help geriatrics prevent harmful falls. For example, in 2011, The American Geriatric Society published an article titled, “New Guidelines for Preventing Falls in the Elderly Include: Start Tai Chi, Cut-Back on Meds in which the organization highlights the guidelines published in the Journal of the American Geriatrics Society. To reduce the chance of falling, the new recommendations for interventions include: 

 

  • Multifactorial interventions which include exercise for balance, gait and strength training, such as Tai Chi or physical therapy.
  • Environmental adaptation to reduce fall risk factors in the home and in daily activities.
  • Cataract surgery where needed, but they recommend against vision intervention as an individual approach.
  • Medication reduction, regardless of the number of medications prescribed (in 2001 this was only recommended for those on at least four) with particular attention to medications that affect the brain such as sleeping medications and antidepressants.
  • Focus on raising low blood pressure and managing heart rate and rhythm abnormalities.

 

This list is of particular importance because major organizations such as the American Geriatric Society and the CDC have openly accepted Tai Chi as a front-line approach to help prevent and manage geriatric falls.

 

Research showing Tai Chi’s ability to decrease falls

 

Not just about balance and balance disorders, Tai Chi enhances physical function and subsequently aids in fall-reduction in older adults. Research has shown, therefore, that people who practice Tai Chi regularly are at a much lesser risk of experiencing debilitating falls later in life.

 

  • In 2003, the Journal of Rheumatology published a very ambitious study in which South Korean researchers from Soonchunhyang University tested the “effects of Tai Chi exercise on pain, balance, muscle strength and perceived difficulties in physical functioning in older women with osteoarthritis” on 72 women over a 12-week period. To be expected, they found that the experimental group perceived significantly less pain and stiffness in their joints and reported fewer perceived difficulties in physical functioning. On the other hand, the control group showed no change or even deterioration in physical functioning after the 12 weeks. In the physical fitness test, there were significant improvements in balance and abdominal muscle strength for the Tai Chi exercise group. Interestingly, no significant differences were found in flexibility and upper-body or knee muscle strength. Nonetheless, the researchers concluded that, “Older women with OA were able to safely perform the 12 forms of Sun-style Tai Chi exercise for 12 weeks, and this was effective in improving their arthritic symptoms, balance, and physical functioning.” Inadvertently, they also proved that Tai Chi is delightfully effective in staving off geriatric falls as one of the primary cause of falls – muscle strength – was directly improved.
  • Likewise, to determine the effect on balance and strength, University of Connecticut School of Medicine recruited 110 participants to engage in 3 months of intensive balance and/or weight training followed by 6 months of low intensity Tai Chi training for maintenance of gains. Subjects were 110 healthy and were an average age of 80 years. They were free of dementia, neurological disease, and serious cardiovascular or musculoskeletal conditions. Short-term training lasting 3 months occurred 3 times per week. Balance training included equilibrium control exercises on firm and foam surfaces and center-of-pressure biofeedback. Strength training consisted of common lower extremity weight lifting exercises. All subjects then received long-term group Tai Chi instruction for 6 months; one hour per session, one time per week. Balance training meaningfully improved all balance measures by restoring performance to a level analogous to an individual 3 to 10 years younger. Strengthening also increased torque of eight lower extremity movements. Of particular interest is that “gains persisted after 6 months of Tai Chi” suggesting that Tai Chi contributes not only to improved balance, but also strength. Subsequently, their risk for falling also greatly diminished as common risk factors for geriatric falls – muscle weakness and lack of balance – were directly affected.
  • To look at center-of-pressure (COP) excursions beneath the feet, researchers from Beth Israel Deaconess Medical Center conducted a study in which 25 older adults with peripheral neuropathy participated in one-hour group sessions of Yang style Tai Chi three times a week for 24 weeks. Standing postural control was measured with force platform and COP dynamics, plantar sensation and physical function were assessed. Participants of the Tai Chi group exhibited increased complexity of standing COP dynamics, as defined by the presence of fluctuations existing over multiple timescales; improved plantar sensation and overall physical function. These factors contribute to better balance and postural control that ultimately leads to less falls.
  • In 2013, a study was published in the Journal of Physiotherapy in which Tai Chi’s ability to increase postural control was tested for Parkinson’s patients between 40 – 85 years old.  195 participants were recruited and 65 were allocated to participate in a 24-week Tai Chi program, 60-minute sessions, twice a week. The study reported that maximal excursion, directional control, stride length and functional reach, increased considerably for the Tai Chi in comparison to the other two groups in which 65 underwent leg muscles strengthening exercises and 65 upper and lower body stretching regimens. In addition, the Tai Chi group reported significantly less falls and was proven by the research team to be “effective in reducing balance impairments in patients with mild to moderate Parkinson's disease.”
  • The pre-cursor to the above study was one that was published in the world-renown New England of Medicine in 2012. Randomly assigning 195 patients with stage one to four Parkinson’s disease to three similar groups -- Tai Chi, resistance training, and stretching – the patients participated in 60-minute sessions twice a week for 24 weeks. Similar findings with the study above, the researchers reported that, “The Tai Chi group performed consistently better than the resistance-training and stretching groups in maximum excursion… The Tai Chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai Chi lowered the incidence of falls as compared with stretching but not as compared with resistance training.” Fascinatingly, the positive effects of Tai Chi training were “maintained at three months after the intervention” showing that its benefits are not short-lived. In addition to no serious adverse events being observed, the authors concluded, “Tai chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinson's disease, with additional benefits of improved functional capacity and reduced falls.”
  • To compare studies targeting Tai Chi and Qigong and identify the physical and psychological health outcomes shown to be associated with them in adults older than 55, University of Arizona and Arizona State researchers evaluated 36 research reports with a total of 3,799 participants and observed the following: “Significant improvement in clusters of similar outcomes indicated interventions utilizing [Tai Chi and Qigong] may help older adults improve physical function and reduce blood pressure, fall risk, and depression and anxiety. However, as researchers indicated, “Missing from the reviewed reports is a discussion of how spiritual exploration with meditative forms of PA, an important component of these movement activities, may contribute to successful aging.” It would be interesting to learn how the spiritual component contributes to these statistics.
  • Not only a complication of falls, it has been shown that depression can cause falls which highlights their bidirectional relationship. Thus, excessive fear of falling – also associated with depression – greatly increases one’s likelihood to fall. According to University of Toronto researchers, “Both depression and fear of falling are associated with impairment of gait and balance, an association that is mediated through cognitive, sensory, and motor pathways.” To complicate matters, anti-depressant medications can increase the risk of falls thereby putting an elderly individual battling depression between a rock and a hard place. University of Toronto researchers highlight this challenging interplay in an article they published this past year in the American Journal of Geriatric Psychiatry and thus recommend that,” Based on the current state of knowledge, exercise (particularly Tai Chi) and cognitive-behavioral therapy should be considered for the first-line treatment of mild depression in older fallers.”

 

Conclusion

 

As is clearly evident by the vast thousands of people who have participated in Tai Chi related research, it would behoove the elderly to practice Tai Chi at least once per week, if not more. Pleasantly surprisingly, the medical community has jumped on board and are now encouraging their geriatric patients to follow this age-old healing art to help prevent falls. Hopefully, researches will continue to study Tai Chi’s effect on other geriatric conditions so that physicians will see its benefit in other non-balance issues.

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