What’s needed for falls prevention – cognitive or motor training, or both?

Cognition and good motor function are essential for independent living. Falls in older patients herald decline in most other functions and can represent a masked presentation of serious illness. Preventing falls and cognitive decline go hand in hand, and it does seem that even for those with mild cognitive impairment, cognitively challenging physical activity makes a difference to cognition and motor function.¹

Your encouragement to older people to challenge themselves, undertake activities that are challenging, and attempt to constantly stretch both cognition and motor function will be of benefit to both cognition and staying upright (not falling over).

I don’t know the exact mechanism for this, but cognitive load while exercising stimulates several neural networks (especially if music is involved). Potentially, the impact on executive functioning and working memory can be sustained, as long as the challenging activities continue.

Libraries, iwi hauora providers, kaumātua groups and NGOs may be facilitated to provide access to exergaming

One good example is a recent trial that tested exergaming – exercise plus gaming, which is inherently cognitively challenging – on the outcome of falls in older people with normal cognition. The exergaming intervention was the “smart±step” computer game system and older folk were randomised to either:²

• Control – evidence-based educational material about healthy ageing, cognition and falls prevention (this was also provided to the smart±step groups).
• Cognitive-only training – participants played eight computer games using their hands on a custom-built desktop touch pad to respond with forward, backward, left and right moves while seated.
• Cognitive–motor training – participants played the same games but stepped on a Bluetooth-connected (wireless) mat to respond to the game stimuli around a central standing position (see photo).

For example, participants used visuospatial skills to plan and align bricks of different configurations neatly into complete lines. The games progressed in difficulty through five levels. Participants played for 12 months with support from research personnel. Adherence to the programme was high, and participants enjoyed it.²

In short, 769 people were randomised, most were followed up and those in the cognitive–motor group did best. The rate of falls in the cognitive–motor group was nearly 30 per cent lower than the control group (incidence rate ratio = 0.74; 95 per cent confidence interval = 0.56–0.98; p=0.036).²

There was no difference between the seated cognitive-only group and the control group for the primary outcome of rate of falls.²

The proportion of people who fell and the rate of falls per weekly hours of physical activity were significantly lower for the cognitive–motor group relative to controls. The cognitive–motor group also had better quality of life, reduced depressive symptoms and less disability than the control group at 12-month follow-up.²

Secondary outcomes showed that the cognitive-only intervention did have some effect, with multiple falls being significantly reduced in the cognitive-only group compared with the control group.²

A significant improvement in attention and response inhibition (Victoria Stroop Test efficiency time) was found for the cognitive-only group, compared with the control group.²

So, exergaming may not be available to all, but if it was, the standing and moving variety is better in preventing falls. It will challenge us to ensure equitable access to these types of programmes, but libraries, iwi hauora providers, kaumātua groups and NGOs may be facilitated to provide access to exergaming, and retirement villages should be right onto this by now.

Promote healthy ageing however you can. Your older patients and their families and whānau listen to you and follow doctors’ advice, even of late, so keep at it. Empower your older patients to follow their preferences and participate in social and physical activities that can preserve cognition and motor function throughout the later years.

Ngaire Kerse is a professor of general practice and primary health care, and the Joyce Cook Chair in Ageing Well, University of Auckland