Fear of Falling

Original Editor - Lauren Lopez Top Contributors - Lauren Lopez and Kim Jackson

Definition

A fear of falling (FOF) or post-fall syndrome[1] is a person's anxiety towards usual or normal walking or mobilising, with the perception that a fall will occur. It is common after a fall although it can occur in the absence of a fall[2].

FOF has been described as a symptom rather than a diagnosis itself[3]. FOF is common in the elderly and experienced by women more than men[2]. It has the effect of causing functional decline, reduced mobility and further falls[3][4]. Falls are a significant cause of morbidity and mortality. Please see the Falls page for further detail.

Clinical Presentation

Functional Decline

The person may have had a fall or known someone who had a fall and sustained serious injuries. As a result, the person becomes fearful of moving in case they fall and hurt themselves. As a result, they will reduce their usual activities which can show up in a subjective of the person's recent activities or ADLs compared to what they, or a carer, report they used to do. A longer exposure to FOF has been linked with an increased risk of functional decline[5].

Reduced Mobility

The result of reduced ADLs leads to muscle weakness and loss of balance reactions which increases the person's actual chance of falling. Hence a FOF can become a "self-fulfilling prophecy" and a cycle of fear, reduced activity, reduced physical function, falls and injuries and so on.

Anxiety and Depression

In regards to anxiety, Harding et al distinguish between anxiety accompanying the activity e.g. nervous whilst walking outside down a steep path, versus anxiety which prevents activity e.g. "I am anxious at the thought of going outside and falling in the garden and breaking a bone so I am not going to do gardening anymore."

The individual may present with depression and low mood and not being able to participate in their usual ADLs and social roles as a result of their FOF.

Risk Factors for FOF

These are the same as those for falls[3]. Gait changes, poor self-perception of physical health, reduced cognitive function and economic resources have been found to be associated with fear of falling[2].

Diagnostic Procedures

Subjective Assessment

This should include:

  • Recent pattern of activity - over days, months, year
  • History of falls including incident, any subsequent treatment and rehabilitation, life changes (or not) after fall/s
  • Current living situation
  • Current mobility both in the home and in the community
  • Descriptions of activities that cause the person anxiety
  • Medications the person in currently taking
  • Previous treatment for anxiety in general and if/how FOF has been treated in the past

Objective Assessment

This should include:

  • Mobility in functional tasks e.g. transfers on/off chair and bed, walking indoors, walking outdoors, mobilising on steps, mobilising to and from bathroom, what aids (if any) are used or have been tried in the past
  • Balance (see below)
  • Strength of trunk and limbs
  • Level of anxiety (see below)
  • Cognition - although this may fall outside of the physiotherapist's scope of practice

Outcome Measures

FOF

  • Falls Efficacy Scale
  • Falls Efficacy Scale International
  • Fear of Falling Avoidance Behaviour Questionnaire*

Mobility

Balance

Strength

ADLs

Anxiety

  • Hospital Anxiety and Depression Scale[3]

Cognition

*One study[4] has shown that three outcome measures together describe 49.2 percent of the variance in predicting falls. These are the Activities-specific Balance Confidence Scale (38.7%), Fear of Falling Avoidance Behaviour Questionnaire (5.6%), and Timed “Up & Go” Test (4.9%).

Management / Interventions

Take a "treat what you see" approach, address underlying modifiable risk factors e.g. reduce medications with input from doctor, and use exercise to focus on balance training to prevent falls and increase self-efficacy in mobilising.

A 2016 Cochrane study[6] found exercise intervention had a small to moderate effect of FOF immediately post intervention. This effect was small and statistically insignificant over the longer term e.g. up to and over six months. The Cochrane study was limited by bias found in the studies it grouped and further research is needed to strengthen the available evidence for exercise and FOF.

A separate, more recent, Cochrane study[7] of community-dwelling adults over 65 has shown that, in regards to falls, exercise does "reduce the rate of falls and the number of people experiencing falls in older people living in the community". In particular, programmes which incorporated types of exercise such as balance and functional exercises, resistance exercises. Tai Chi was also found to probably reduced falls.

Muscle Strengthening

Elderly adults are at risk of reduced muscle bulk and function but this can be reversed to a degree so a progressive strengthening programme should be initiated.

Balance Training

This can begin with the tasks or activities the individual finds stressful or anxiety-inducing. If this is too difficult, then the activity can be broken down into smaller parts first then progressed from there.

Tai Chi and the Otago Exercise Programme are proven interventions for improving balance which then ideally will produce increased confidence in mobilising.

Build Self-efficacy

Recent research[8] suggests that when FOF is viewed in the context of post traumatic stress disorder, FOF is not just negative but can be either maladaptative (as described above) or adaptive e.g. the individual takes care when navigating challenging balance situations but does not avoid them altogether. As a result, the authors suggest that building the individual's self-efficacy is a valuable tool for addressing a maladaptive FOF.

Building self-efficacy could involve psychological techniques e.g. cognitive behavioural therapy, practising the tasks or activities that cause anxiety, working with the person to find strategies, teaching the person to reflect on their abilities and successes, increasing physical performance e.g. muscle strengthening, balance training.

Goal setting may help guide treatment and help engage the anxious person in treatment by providing a meaningful outcome to work towards.

Involve and Carers and Significant Others

As the elderly often have support whether they live in the community or in care facilities, it is valuable to engage their carers or family to carry out exercises, home modifications and supervise the older adult in challenging mobility situations.

Resources

Physiopedia's Falls category

NeuRa

References

  1. Murphy J, Isaacs B. The post-fall syndrome. A study of 36 elderly patients. Gerontology. 1982. 28;4:265-70.
  2. 2.0 2.1 2.2 Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997 May. 26;3:189-93. Accessed 25 September 2019.
  3. 3.0 3.1 3.2 3.3 Harding S, Gardner A. Fear of falling. Aust J Adv Nurs. 2009. 27;1: 94-100. Accessed 25 September 2019.
  4. 4.0 4.1 Landers MR, Oscar S, Sasaoka J, Vaughn K. Balance Confidence and Fear of Falling Avoidance Behavior Are Most Predictive of Falling in Older Adults: Prospective Analysis. Phys Ther. 2016. 96;4:433–442. Accessed 25 September 2019.
  5. Choi K, Jeon G, Cho S. Prospective Study on the Impact of Fear of Falling on Functional Decline among Community Dwelling Elderly Women. Int J Environ Res Public Health. 2017. 14;5: 469. Accessed 25 September 2019.
  6. Kumar A, Delbaere K, Zijlstra GAR, Carpenter H, Iliffe S, Masud T, Skelton D, Morris R, Kendrick D. Exercise for reducing fear of falling in older people living in the community: Cochrane systematic review and meta-analysis. Age and Ageing. 2016. 45; 3:345–352. Accessed 26 September 2019.
  7. Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD012424. DOI: 10.1002/14651858.CD012424.pub2. Accessed 26 September 2019.
  8. Adamczewska A, Nyman SR. A New Approach to Fear of Falls From Connections With the Posttraumatic Stress Disorder Literature. Gerontol Geriatr Med. 2018 Jan-Dec; 4: 2333721418796238. Published online 2018 Aug 27. doi: 10.1177/2333721418796238. Accessed 25 September 2019.