Fear of falling By Andrew Walker

Objectives Describe falls statistics. Describe fear of falling. Describe fear of falling statistics Discuss how fear of falling should be measured. Discuss how this affects our practice.

Falling – Grim Statistics… 1 in 3 people over 65 have a fall each year. 1 in 2 people over 80 have a fall each year. –Redbridge population over 65 =  Potential for approx falls per year in Redbridge each year Projections suggest that by 2015 the incidence of hip fractures will be 120,000 annually. (Johnell et al., 1992)

Department of Health

Results of a 12 month audit (April 2003 – March 2004) of people over 65 with a Redbridge postcode admitted with a fractured Neck of Femur (NOF): –Oldchurch6 –KGH150 –Whipps Cross89 This totals 245 patients. Hence 2% of potential falls over the age of 65 cause fracture. Grim Statistics (cont)…

With average acute inpatient stay costing £7,200, Redbridge’s 245 fractured NOFs cost £1.7 million. (Not accounting for social/aftercare) The cost of hip fractures nationwide *More than ½ cost is social care ( Department of Health)

1 in 5 people with hip fracture die within 6 months. After a fracture 50% of patients cannot live independently.

How do the over 65’s fall? (i.e. from chair or bed) Types of falls in UK in persons aged over 65: (Department of Health)

What is Fear of falling? Not only found amongst those who have had falls (Arfken, 1994) Infact it is the top fear when ranked against other common fears in elderly persons (Walker, 1991) In fallers and non fallers, poor mental and physical health are linked with fear of falling limiting activity (Bruce, 2002; Murphy, 2002; Howland, 1998 and Tinetti, 1994) “Individuals with no falls history, but a fear of falling have an increased risk of admission to an elderly care facility” (Cumming et al. 2000)

Fear of Falling stats 50% of fallers had a fear of falling. 25% of non-fallers had a fear of falling. (Walker, 1991 and Tinetti, 1993) A recent study in the Chingford area showed that 1 in 10 community dwelling women entering old age (54-77) had a fear of falling limiting activity. (Martin et al., 2005)

Fear of falling leads to significantly lower gait speed, shorter stride length, wider stride width (i,.e base of support) and increased double limb support time (Chamberlin, 2005) Studies agree that fear of falling indicates a reduced ability to partake in ADLs. However, there is still debate as to the degree to which psychological factors (I.e depression) precipitate the fear (Martin et al., 2005)

Often assessed as a dichotomous concept.  “Are you worried about the possibility of falling over?” yes/no answer.  Some clinicians may take a description of this fear. The yes/no answer does not give any idea as to what the fear relates to, or what the fear leads to. I.e. activity restriction. A description means that the individual has to appreciate their fear.

The concept of self-efficacy has been applied to fear of falling. Self efficacy (Bandura, 1982) is a psychological concept based upon an individuals perceived capability within a domain of activity. –Fear of falling = "low perceived self-efficacy at avoiding falls during essential, nonhazardous activities of daily living.“ (Tinetti, 1990)

How do we measure it? Assessing falls related self efficacy in specific activities/tasks reveals the extend to which the individual feels they can take part in an activity without falling. 2 Measurement tools have been developed: –Falls efficacy scale (FES) (Tinetti, 1990) –Activities-specific Balance Confidence (ABC) scale. (Powell, 1995)

FES Interview 10 items related to independent living. 10-point continuum per item. High score=low efficacy. Possible scores range from Time ≈ 10mins Cost = 0 ABC Interview 16 items related to independent living. 100 (%) point continuum per item. High score = high efficacy Possible scores range from Time + Cost ?

These objective measures outline the degree of fear of falling and the domain/activity that it is exhibited. “In the last 12 months have you limited your activities because you are afraid you will fall?” This type of closed question has been shown to correlate with the FES (Lachman, 1998)

How does this affect our practice? We all meet patients that have fear of falling. We can objectively measure it using the ABC or the FES. (Both tested for validity and reliability in measuring fear of falling) “In the last 12 months have you limited your activities because you are afraid you will fall?” correlates with the FES and may be first option to screen need to do full test.

By affectively addressing fear of falling, it will reduce the risk and expense of falls that the NHS incurs Studies suggest that fear of falling is exhibited in gait. Hence gait re-education can impact on the falls risk in those who have or have not fallen.

An Oxfordshire based study has shown that older people can reap big benefits from targeted exercise programmes (Ramsbottom, 2004) –12% faster timed walking test. –40% increase in leg power. Hence patients benefit from our intervention. Be it referral to ICT, social service, falls clinic, community and outpatient physio services.

Many thanks!

References M.E. Chamberlin et al. (2005) Does Fear of Falling Influence Spatial and Temporal Gait Parameters. J Geront. A Biol. Sci. Med. Sci, 60(9), F. Li, et al. (2005) Falls self-efficacy as a mediator of fear of falling in an exercise intervention for older adults. J Geront. B Psychol. Sci. Soc. Sci, 60(1), N. Gagnon, et al. (2005) Affective correlates of fear of falling in elderly persons. Am J Geriatr Psychiatry, 13(1), S. L., Murphy et al. (2003) The development of fear of falling among community-living older women. J. Gerontol. A Biol. Sci. Med. Sci, 58(10), M F. Li., et al. (2003) Fear of falling in elderly persons: association with falls, functional ability. J Geront. B. Psychol. Sci. Soc. Sci, 58(3), B. Brouwer, et al. (2004) Physical function and health status among seniors with and without fear of falling. Gerontology, 50(3), M. Lachman, et al., (1998) A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol B Psychol Sci Soc Sci, 53B, F. Martin et al., (2005) Fear of falling limiting activity in young-old women is associated with reduced functional mobility rather than psychological factors. Age and Ageing, 34(3)

References R. Kurlan, (2005) "Fear of falling" gait: a potentially reversible psychogenic gait disorder. Cogn Behav Neurol.18(3), J. Hatch, (2003) Determinants of Balance Confidence in Community-Dwelling Elderly People. Physical therapy, 83(12) M. Tinetti (1990) Falls efficacy as a measure of fear of falling. J Gerontology, 45, M. Tinetti (1993) Fear of falling and low self-efficacy: a case of dependence in elderly persons. J Gerontol. 48, L. Powel, (1995) The Activities-Specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci, 50, M28-M34. R. Ramsbottom, et al., (2004) The effect of 6 months training on leg power, balance, and functional mobility of independently living adults over 70 years old, J Aging Phys Act. 12(4), A. Bandura (1982) Self-efficacy mechanism in human agency. Am Psychol, 37, J. Walker (1991) Falls and fear of falling among elderly persons living in the community: occupational therapy interventions. Am J Occup Ther, 45, R. Cumming (2000) Prospective study of the impact of fear of falling on activities of daily living. J Gerontol Med Sci, 55A, M