Fear of Falling A Primer for Caregivers

Older adults have every reason to be concerned about falls. About one third of 65-year-old or older persons living in the community fall every year, and more than half of those living in institutions fall every year. Both the incidence of falls and the severity of complications increase with age and increased disability and functional impairment.

While the vast majority of these falls do not result in serious injury, for many older adults, an injurious fall is the beginning of a downward trend characterized by loss of independence, isolation, and possibly death.

Over the last decade, there has been increasing interest in understanding the causes of falls and developing interventions to prevent falling among older adults. Research to date suggests that falls among older adults can be prevented through fairly simple programs designed to improve strength and balance and reduce medications3-5. Only recently has there been focus on fear of falling. Previously, fear of falling was studied as a consequence of experiencing a serious fall. In recent years, however, a number of epidemiological studies have been conducted on fear of falling among the general elderly population. Although some may view fear of falling as a protective, rational response to the realities of aging, a growing body of evidence suggests fear of falling deserves the attention of all providers of care for older adults. This article is intended to help you understand fear of falling and its implications.

Fear of falling is common

Several studies addressing the prevalence of fear of falling have been conducted over recent years. Although each of these studies asked about fear of falling in slightly different ways, there is relative consistency and it appears that somewhere between a third and a half of the community-dwelling elderly acknowledge fear of falling6-8. Therefore, these studies’ findings indicate that fear of falling is a shared concern among community-dwelling older adults.

Fear of falling leads to inactivity

If the fear of falling is intense, it can limit mobility9. In doing so, it can reduce physical activity and thus lead to reduced physical conditioning. One consequence of reduced physical conditioning could be increased risk for falls. Thus, while it could be argued that limiting activity due to fear of falling limits opportunities for falling, it might also increase the risk for falling when necessary activity (e. g., answering the door or telephone, using the bathroom) occurs. There is increasing evidence of the role of physical activity in maintaining overall health status.

Falls self-efficacy – the belief that one can engage in activities without falling – has been shown to positively contribute to mental health (mood), emotional functioning (extent to which emotional problems interfered with desired activities), social functioning (extent to which health problems interfered with normal social activities), life satisfaction, and leisure activities. Older adults who are inactive due to fear of falling may lose confidence in their ability to safely carry out routine activities of daily living. This erosion of confidence can lead to a downward spiral characterized by further dependence and self-doubt.

Similarly, fear of falling could result in reduced leisure activities, such as getting together with friends or going out for entertainment and thus resulting in social isolation. The relationship between falls self-efficacy and well-being, independent of risk factors for falls, underscores the importance of falls selfefficacy as a vital characteristic for healthy aging.

Is intervention for fear of falling possible?

A Matter of Balance is a program specifically designed to reduce fear of falling and improve activity levels among community- dwelling older adults. The program was developed, implemented, and tested under the auspices of the Roybal Center for Research in Applied Gerontology located at Boston University (BU) and the New England Research Institutes (NERI). In November 1999 the intervention was recognized by the American Public Health Association with the Archstone Foundation Award for Excellence in Program Innovation.

A Matter of Balance acknowledges the risk of falling but emphasizes practical coping strategies to reduce the sequelae of fear of falling. It is a structured group intervention consisting of nine two-hour sessions that utilize a variety of activities to address physical, social, and cognitive factors affecting fear of falling.

Building upon Bandura’s work that links optimal performance to adaptive self-conceptions, the central focus of A Matter of Balance is to build falls self-efficacy. The program features several strategies to enhance falls self-efficacy. Examples of these strategies include:

Skills mastery

In order to enhance participants’ confidence in their own abilities to make adaptive changes in their lives, many opportunities to build fall prevention skills are provided. These skills include exercise training, assertive communication, and environmental assessment.

Modeling

A video created for the program is used in order to expose participants to realistic, adaptive role models.

Reinterpretation of signs and symptoms

Participants are taught to recognize the connection between thoughts (“My balance is so bad I can’t do things on my own”), feelings (anxiety), and behaviors (restricted activity).

Persuasion

In the group setting, persuasion is provided through feedback from the other participants and program facilitator. Realistic goals, once achieved, also provide older adults with persuasive, objective proof that progress in fall prevention is possible.

The randomized field trial undertaken to evaluate the program enrolled 434 residents of senior housing, age 60 or older, who reported activity restriction due to fear of falling. Data were collected at baseline, six weeks, six months, and 12 months. Results showed a significant increase in falls efficacy and ability to manage fall risk and fewer mobility and activity restrictions for persons in the intervention group versus control group immediately after the intervention.

Long term effects included improved social functioning and mobility range. Sustained attitudinal change was found in subjects attending more intervention sessions. (Tennstedt, S., Howland, J., Lachman, M.E., Peterson, E.W., Kasten, L., & Jette, A. 1998).

Falls were monitored in the intervention and control groups to ensure that the program did not increase falls as a consequence of increasing activity. There were no significant differences between groups in either the number of participants who fell or in the number of falls during the follow-up period.

By demonstrating the efficacy of the intervention, the study has helped to make fear of falling clinically relevant. We now know that the fear itself, and the activity restriction associated with it, can be mitigated. Moreover, this study tends to support the view that fear of falling is a cause of restricted mobility and reduced social interaction.

An extensive effort to disseminate A Matter of Balance is now underway. Opportunities for delivering A Matter of Balance include: senior centers, in-patient and out-patient rehabilitation facilities, senior housing, assisted living facilities, nursing homes and community base wellness centers.

What causes fear of falling?

As previously mentioned, fear of falling among the elderly might be viewed as an appropriate and even protective response to a likely and potentially devastating event. There is no doubt that fear of injury resulting from a fall is real and common.

Nevertheless, in focus groups older adults have described falls as sentinel events for institutionalization12. Thus, to some degree fear of falling is related to a fear of loss of independence. Indeed, it has been estimated that 40 per cent of nursing home admissions are precipitated by falls. Moreover, it is often those closest members of an elder’s support group - family and health care providers - who interpret the fall event as an indicator of the need for institutionalization. Accordingly, some elders might hesitate to talk to members of their support group about their concerns about and experiences of falling. This can only increase the impact of this fear and probably accounts for the prevalence and intensity of fear of falling among community-dwelling elders. For this reason, it is incumbent for caregivers who provide services to the elderly to be aware of the prevalence and impact of fear of falling and to be proactive in talking to their clients about falls and fear of falling.

What can you do to reduce fall risk among older adult clients?

Initiate Discussions

Older adults are often reluctant to bring up the issue of falls. Therefore, as a health care provider it is up to you to ask clients about fall-related concerns and experiences.

Identify Risk Factors

Interview clients (and whenever possible key members of their support systems) with the goal of identifying behavioral, environmental, physical, and attitudinal risk factors for falls. Conduct thorough physical examinations, look for ways to improve management of chronic conditions, and evaluate potential medication interactions.

Prioritize

Because falls are caused by many factors (physical, behavioral, environmental), fall prevention efforts are typically diverse in nature. For example, fall prevention strategies for one person may include reducing the number of prescription medications, changing positions slowly to avoid a drop in blood pressure, and installing grab bars by the toilet. After fall risk factors are identified, explain any changes in medical care that address physical risk factors, and help your client decide which environmental or behavioral risk factors to address first. Which change is the easiest to make? Which change will have the greatest positive impact on health? Once your client experiences success in eliminating one risk factor, he/she will be motivated to continue with fall prevention efforts.

Collaborate

Take an active role in creating fall prevention strategies with your client. After all, your clients are the experts on their own needs, lifestyle and goals. Remember that if your client is dissatisfied with a plan to reduce fall risk, it is unlikely that he/she will follow through with it.

Encourage Exercise

Exercises that improve balance, such as Tai Chi, have been shown to reduce fall risk. Explore community resources to find an exercise program that will work best for your client.

Allow Assertiveness

Making requests of health care providers is not always easy for older adults. Congratulate clients who take an active role in their health care. Remind clients that asking for help is not a sign of dependence. Such requests are simply a way to help your client avoid a fall and maintain independence.

Create a Contingency Plan

Your client should know what to do if he/she should fall when alone. Talk to your client about the best way to get up after a fall. Help your client make a plan to access help and arrange for routine checks to ensure safety.

Ask for Updates

Older adults sometimes dismiss noninjurious falls as unimportant. Tell your client to report any fall to you. Explain that falls are often a symptom of a condition that can be easily managed.

What can you do to reduce fear of falling among older adult clients?

Acknowledge the Concern

Tell your client that fear of falling is a rational response to a real threat to independence and that many older adults share this concern. Remind them that being aware of concerns about falls and how falls impact physical or emotional health is the first step in managing the fear of falling.

Explore Attitudes

Negative attitudes about aging and fall prevention (“exercise is dangerous at my age”) will block your client’s desire and ability to take positive steps toward preventing falls. On the other hand, positive thoughts inspire action. Take time to examine and address attitudes and beliefs underlying your client’s statements and actions.

Involve Support Systems

Among older adults who are afraid of falling, those who have family, friends, and significant others that they can turn to for help and advice are less likely to curtail their activity. Help your client avoid the negative physical and emotional consequences of inactivity by involving others in your client’s fall prevention efforts.

Practice, Practice, Practice

In order to gain confidence in abilities to reduce fall risk, your client will need to prove to him/herself that he / she has the skills necessary. The skills needed will vary depending upon your client’s unique fall risk factors. Common skills used to prevent falls include communicating assertively, exercising regularly, and finding alternative approaches to potentially risky behaviors. Referring your client to occupational and/or physical therapy is one way to provide opportunities for skill building.

Be a Problem Solver

Needs change over time. Re-evaluate your client’s fall risk factors, help him/her set goals, and create plans of action. Identify potential barriers to accomplishing goals up front and create a plan to address those threats to success.