PROF CELIA TAN
Prof Celia Tan has 39 years of experience in the healthcare sector, is an active clinician, as well as teacher in Physiotherapy both locally and overseas. She also has a keen interest in research on spinal pain, innovative robotics and exercise therapy for chronic diseases, such as frailty and cancer. As an administrator, Prof Tan has helped to establish clinical, education and research units in SingHealth (SHS), such as Satellite Rehabilitation Services, Postgraduate Allied Health Institute (PGAHI) and Singapore General Hospital (SGH) LIFE Centre for health promotion. Prof Tan is currently Senior Director, Special Projects in SHS and held the position of Group Director, Allied Health for 3 terms (9 years). She is also actively involved in teaching at PGAHI and the new College of Allied Health under SHS, which provides much needed continuing clinical training for local and overseas Asian Allied Health professionals, as well as training for educators and researchers.
What are the most common causes of falls among the elderly?
Falls are a very big topic. In Singapore, one in three community-dwelling people over the age of 65 years falls each year, and the rate of related injuries increases with age. 1
Falls among older people can usually be attributed to musculoskeletal weaknesses or poor muscle coordination. They can also occur due to age related changes in eyesight, hearing and reflexes. Additionally, conditions like diabetes, heart disease, thyroid problems, nerve issues, foot problems, and blood vessel problems can affect balance and increase the risk of falling. Lack of exercise due to chronic diseases or decreased confidence can also lead to muscle degeneration and bone weakness, further exacerbating the risk of falls. Older adults with mild cognitive impairment or certain types of dementia are also at greater risk. On top of the above, certain medications can increase a person’s risk of falling because they cause side effects such as dizziness or confusion. The more medications you take, the more likely you are to fall.
At what age should we start to worry about the risk of falling?
Falls can happen to anyone at any age but the risk of falling increases as we grow older, and/or are weaker due to chronic diseases or a sedentary lifestyle.
We should probably start to worry when we start to feel the effects of ageing, but the exact age for that varies from person to person. For someone who exercises regularly, it could be 60 or even older. For those who have chronic diseases, it could be around the age of 50. You may feel extra tired when you wouldn’t normally feel tired, or no longer be able to push yourself when you go for exercise, no matter how hard you try.
What can be done to prevent falls?
First, you should attend to any underlying medical conditions. For example, if you have osteoporosis (bone loss), diabetes or high cholesterol, you should get the necessary treatment and medication to bring such chronic conditions under control. Doing so will help you learn to live with these conditions so that you won’t increase your risk of falling. Although it is inevitable that our bodies will get weaker as we age, the good news is that many of these weaknesses are not irreversible. We can train our body to regain strength and improve our balance. However, it does take an older person longer to do so compared to a young person.
Are there specific exercises or physical activities that older adults can engage in to improve balance and reduce the risk of falling?
Several exercises can help older adults improve balance and lower-body strength. Balance exercises such as standing with feet together, tandem standing (standing with the toe of one foot right behind the heel of the other), standing on one leg, and standing on toes can be beneficial. The first thing I usually ask my patients to do is to practice standing on one leg. Most people think they can do it, but many cannot, even the younger ones. However, you can certainly do it with enough practice. My advice to my patients is to practice it every hour for 1–2 minutes. Just balance on one leg for as long as you can, then switch to the other leg.
Most people find that they can balance well on one leg after about a week of practice. But do have a firm chair or table next to you initially so that you can hold on to it in case you lose your balance.
Older, wiser, stronger
Elderly and middle-aged people exercise with wooden dumbbells
during a health promotion event to mark Japan’s “Respect for the
Aged Day” (敬老の日, Keirō no Hi) at a temple in Tokyo’s Sugamo
district, an area popular among the Japanese elderly.
Photo: Issei Kato / REUTERS
Besides balancing, it is also important to build strength in the leg muscles. A good way to train strength is the sit-to-stand exercise. You stand up from a sitting position on a chair without using your hands for support and repeat that about five times continuously. An advanced version of that is to stand up from a half-squatting position with your back leaning against a wall often referred to as the wall squat.
These are the two basic things I advise my patients to practice. In fact, if an old person does not practise balancing and regain enough strength in the legs, they will be at much greater risk of falling in precarious situations.
I always enjoy the happy expression on my patients’ faces when they tell me how surprised they are that they can regain balance and strength after they thought they have lost them for good.
Other activities such as Tai-chi, Pilates, yoga, and walking can also help to build strength in the legs, which can improve balance. More advanced exercises like dancing, jogging, stair climbing, badminton, and table tennis can further enhance coordination, balance, and strength. A systematic review has shown that exercise can reduce the rate of falls by 23%, particularly when incorporating balance and functional exercises in their exercise routine.2
How can seniors effectively navigate stairs safely, especially if they have mobility or balance issues?
Stair climbing is tricky because it requires both strength and balance to carry the body weight up the stairs or to hold back the body weight down the stairs, all on one leg. It is especially challenging for seniors with mobility or balance issues. For people living with these conditions, it is best to avoid stairs altogether and use elevators instead, but that is not always possible even in a pedestrian-friendly place like Singapore.
Smart home upgrades for ageing in place
From smart door locks, security systems, automated lights and medication reminder to smart hubs that control all of the smart devices, smart home upgrades can help the elderly, including those with mobility challenges and other health issues, age in place safely. Photo: Jovanmandic / iStock
To ensure safety when one has no choice but to use stairs, it is important to have a sturdy railing or support that can be used for stability. Rugs or any obstacles should be removed from the staircases.
Step height should not be too high, and the edge of each step should be clearly marked. Stairs should be well-lit. Non-slip flooring should be used whenever possible, and wet stairs should be avoided.
Moving escalators are the worst and should be avoided if possible. They can be scary for seniors because the height of the moving steps changes very quickly, and poor eyesight can make it difficult to tell the boundary of a step. The timing to step on and get off can also be difficult to judge for an elderly person. Some of the escalators have yellow markings to help but many still don’t.
Specific strengthening and balance exercises, such as wall squats, step-ups, step-downs, and standing on one leg, can help improve stair-climbing abilities and reduce falling risk on stairs. Walking downstairs is especially challenging because it requires eccentric (muscle lengthening) strength in your quadriceps which needs to be trained differently from concentric (muscle contraction) strength. For stability, it is also important to have your entire foot land firmly on the step instead of having your heels or toes hanging from the edge when you walk up or down staircases.
Are there any particular home modifications or adaptations that can enhance the safety and accessibility of living spaces for older adults?
In living spaces for the elderly, high-risk areas should be identified and appropriately modified to reduce fall risks. For example, non-slip floors can be installed in areas prone to wetness, such as bathrooms and kitchens. Support railings should be installed in high-risk areas like bathrooms and staircases.
Floors should be kept dry and clean, and non-slip mats can be used to prevent slipping. Furniture for sitting-to-standing transitions should be firm and stable. Motion sensor lights can be installed in areas that tend to be dark, such as bedrooms, toilets, and kitchens. Light switches should be easily accessible
and clearly marked. Stairs or steps should be minimised whenever possible, and when necessary, they should be clearly demarcated.
It is quite common for the elderly to fall when they get up to use the toilet in the middle of the night. Consideration can be given to using a bedside commode to avoid frequent trips to the toilet.
Senior people also tend to have accumulated more belongings at home. When they are not properly stored and organised, these things take up space, obstruct light, make moving around more difficult and tripping more likely. It is therefore important to declutter living spaces so that walkways are always clear and well-lit.
What are the key factors that contribute to maintaining or improving strength and mobility in older age?
Two key factors that need to be addressed are sarcopenia, age-related muscle loss, and osteoporosis, which is bone loss.
Evidence suggests that skeletal muscle mass and skeletal muscle strength decline in a linear fashion beginning as early as age 40, with up to 50% of mass being lost by the 8th decade of one’s life.3 Changes in strength, swiftness, and stamina with age are all associated with decreasing muscle mass, and it is one of the most important causes of functional decline and loss of independence in older adults.
Singapore has the highest reported incidence of hip fractures in Asia. The International Osteoporosis Foundation Asian Audit showed that one in three Singaporean women over 50 years old has osteoporosis. 4Having a routine for regular exercise and proper nutrition intake plays crucial roles in combating these conditions. Resistance and endurance exercises have been shown to prevent the development of osteoporosis and sarcopenia. Adequate protein and vitamin D intake, along with a healthy diet, also play a protective role. However, further research is needed to fully understand the effects of exercise and nutrition on these conditions. For better quality of life, it is also important to maintain cardiovascular fitness. The best exercise for the elderly to sustain cardio fitness is brisk walking. The guideline for this is to maintain your heart rate at 110–120 beats per minute for about 30 minutes as you walk.
If you do not wear a heart-rate tracking device, you should brisk walk at a pace that allows you to talk but not sing.
Aquatic exercise for the elderly
Aquatic exercise is a low-impact activity that is particularly effective in improving the muscular strength and endurance of the elderly who suffer from arthritis, stiff joints and other health problems. It also helps improve cardiovascular health, increase flexibility and mobility, and reduce stress. Photo: Athit Perawongmetha / REUTERS
Can you provide tips or recommendations on how to prevent injuries while performing daily activities like lifting or
When lifting, one should avoid bending the back and When lifting, one should avoid bending the back and use the strength of the legs instead. Heavy loads exceeding 20 kg should be avoided, and strength in the spine and lower limbs should be developed to prevent lifting injuries. Twisting of the back while carrying heavy objects should be minimised. Objects should be carried as close to the body as possible to reduce strain on the spine. Performing stretches also relaxes the muscles and
prevent the pinching of spinal nerves.
It is important to note that pain happens in the joints when the muscles are not strong enough to hold the bones apart when one moves, or when the muscles are too tight to keep the bones from pressing onto one another. Strengthening and stretching one’s muscles helps avoid pain in the joints.
How can older adults maintain an active lifestyle while minimising the risk of injury or strain?
Older adults should follow a prescribed exercise routine that is appropriate for their fitness level and health condition. Exercise dosage is key for effective results. One should exercise at least 3 times for a minimum of 150 minutes per week. Again, it is important to sustain a heart rate of 110-120 per minute during exercise, or at a pace where you can still talk but not sing.
While being active is good, overexertion should be avoided. Sufficient rest should be allowed between exercise sessions to allow for a full recovery.
Stretching exercises should be incorporated before and after workouts to relax the muscles and prevent injury. If pain occurs during exercise, rest should be taken, and the exercise can be tried again later. If the pain persists, it is advisable to consult a doctor.
Consuming a varied diet to meet nutritional needs is also important. Doing so gives the body the necessary strength and helps the body to recover. It is also a good idea to exercise in a group. Having companionship, mutual encouragement and
accountability helps to motivate people to sustain good habits and a healthy lifestyle.
For older adults with pre-existing health conditions, are there specific considerations or precautions that should be taken when engaging in exercise or physical activities?
For those with pre-existing health conditions, it is important to consult a doctor for clearance and guidance before engaging in physical activities.
Precautions and considerations may vary depending on the specific health condition. For example, individuals with diabetes are recommended to avoid very strenuous activity and heavy lifting, while those with heart disease should be cautious with extreme temperatures and strenuous exercises. Following medical advice and personalised exercise plans can help ensure safety and optimize the benefits of physical activities.
With medical advancements, degenerated body parts can now be replaced or repaired with injection or surgery. Instead of making the effort to exercise regularly to prevent deterioration and loss of strength, should these solutions be considered? Compared to previous generations, we now live longer and need to keep our bodies functional for a longer period of time. In my opinion, it is advisable to rely on natural solutions to stay healthy for as long as we can. While some of these medical solutions are very effective in solving certain musculoskeletal problems, they should be considered as a last resort when the degeneration can no longer be reversed using routine exercises or other natural ways.