How should we manage fear of falling in older adults living in the community?
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2933 (Published 28 May 2013) Cite this as: BMJ 2013;346:f2933
- Steve W Parry, clinical senior lecturer and consultant physician1,
- Tracy Finch, senior lecturer2,
- Vincent Deary, senior lecturer in psychology3
- 1Falls and Syncope Service and Institute for Ageing and Health, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
- 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne NE2 4AX, UK
- 3Department of Psychology, Northumbria University, Newcastle upon Tyne NE1 8ST, UK
- Correspondence to: S W Parry steve.parry{at}nuth.nhs.uk; swparry{at}hotmail.com
- Accepted 15 February 2013
Many older people have a variety of adverse psychosocial difficulties related to falling, including fear, anxiety, loss of confidence, and impaired perception of ability to walk safely without falling.1 2 The umbrella term for these problems is “fear of falling,” and this is found in around half of community dwelling older people who fall and in up to half of those who have never fallen.1 2 Consequences include avoidance of activity, social isolation, and increasing frailty and risk of further falls independent of physical impairment.2 3 Although fear of falling is both common and debilitating, understanding of its management is limited. Some evidence supports the use of physical therapies to improve the syndrome, and emerging evidence supports the use of psychological therapies, in particular cognitive behavioural therapy. However, as a recent systematic review and meta-analysis have shown,1 3 no definitive studies exist to guide routine practice in this area. Furthermore, data showing how such interventions could be translated from research to clinical settings are sparse; only one randomised controlled trial of a complex intervention in fear of falling has attempted such evaluation.4 Health economic data about intervention in this common clinical problem are not yet available.
What is the evidence of the uncertainty?
We searched PubMed, Medline, CINAHL, Cochrane, and Embase online databases for studies related to interventions in fear of falling in community dwelling older adults to explore this question further.
Physical and falls risk factor interventions
Concerns about falling have a clear effect on gait patterns in older people. Laboratory studies of asymptomatic older people undergoing gait and balance studies on elevated walkways show disproportionately slow walking speeds and other dysfunctional gait adjustments,5 alongside abnormalities in postural balance compared with younger subjects.6 Such experimental data and the observation of higher risk of falls and increasing physical frailty in fear of falling suggest that physical and general interventions may help to ameliorate fear of falling.
In a systematic review of 19 randomised controlled trials that measured fear of falling as an outcome, of the 12 studies of higher methodological quality only three targeted fear of falling directly.1 Overall, the review found that multifactorial programmes targeting falls in general, home based exercise interventions, balance training, and, in one study, hip protectors all improved fear of falling, although in the majority this was a secondary rather than a primary outcome measure.1 These were mostly studies of ambulatory adults aged over 60, and the Falls Efficacy Scale was the most common measure of fear of falling. Only one randomised controlled study of a community based, physiotherapy led exercise intervention versus usual care in 165 over 65 year olds found no improvement in fear of falling.7 In the three randomised controlled trials in which fear of falling was specifically investigated, a multicomponent cognitive behavioural therapy approach (n= 434), a small group learning programme (n=310), and a Tai Chi intervention (n=49) all led to statistically significant (P<0.05) reductions in fear of falling in the treatment groups as measured by the Falls Efficacy Scale.8 9 10 However, in the trial of cognitive behavioural therapy this was only in a per protocol analysis.8
A later meta-analysis of nine studies examining Tai Chi in the management of fall prevention, fear of falling, and balance in older adults concluded that insufficient evidence existed to recommend such an intervention in this context.3 To confuse things further, a more recent small (176 participants in three intervention groups) randomised controlled study of intense Tai Chi with cognitive behavioural strategies versus Tai Chi alone and control groups showed a benefit. The Tai-Chi plus cognitive behavioural therapy group had a significant improvement in Falls Efficacy Scale scores compared with the other two groups.11 So, although Tai Chi can help to prevent falls in older adults,12 its role specifically in the management of fear of falling is less clear.
Multicomponent interventions published since the 2007 systematic review have increased the uncertainty surrounding such interventions. A recent randomised controlled trial of three strength and balance exercise regimens versus usual care in 280 participants with fear of falling found no improvement in fall related psychological outcomes.13 A randomised controlled study of comprehensive personalised falls risk assessment and treatment compared with usual care in 392 older people similarly showed no improvement in fear of falling.14 The two larger studies we identified thus did not provide support for physical interventions in fear of falling.13 14
Psychological interventions
The traditional conceptualisation of fear of falling’s basis in avoidance of activity and deconditioning are likely to be simplistic,8 15 and the causes and maintenance of the condition are probably more multifactorial in origin and maintenance.16 Studies of cognitive behavioural therapy to target fear of falling provide some support of effectiveness. One such randomised controlled trial of cognitive behavioural therapy versus a social contact only control in 434 older adults, mentioned above,1 8 showed a significant effect on falls and fear of falling when treatment compliance was accounted for. This group cognitive behavioural therapy protocol was modified and trialled in a Dutch randomised controlled trial of the cognitive behavioural group intervention versus usual care in 540 older adults.15 At the 14 month follow-up, 24.5% of the intervention group reported substantial fear of falling as opposed to 41.7% of the control group, although the high attrition rates (30% v 20%) limit the generalisability of these data.15 The only other higher quality recent study involving cognitive behavioural therapy was in association with Tai Chi as described above, showing a significant effect on falls efficacy when combined with Tai Chi.11 The relative effectiveness of group based and individual based psychological interventions remains uncertain. A theoretical re-examination of models of fear of falling and a recent cohort study of 500 older adults both suggest that the fear of falling population is a complex and heterogeneous one, in which psychosocial and physiological interventions also need to be individualised.16 17 To date, none of the trials has taken this variation into account.
Is ongoing research likely to provide relevant evidence?
We are conducting a randomised controlled trial, the StRIDE (Strategies to incRease confidence, InDependence and Energy) study, of an individualised cognitive behavioural therapy treatment, delivered by trained healthcare assistant level staff, versus treatment as usual in 582 community dwelling adults with fear of falling as measured by the Falls Efficacy Scale International,18 our primary outcome measure. This study will also provide comprehensive process and health economic evaluations to guide practical implementation.19 We also searched the databases mentioned above and the US National Institutes for Health’s ClinicalTrials.gov and ISRCTN databases for relevant studies. Ongoing randomised studies are trialling an individualised home based cognitive behavioural therapy programme versus no treatment in 140 elderly adults with fear of falling and an exposure therapy and cognitive restructuring approach versus an educational control in 40 adults with fear of falling.20 21 Both studies are using the Falls Efficacy Scale as a primary outcome measure. Another randomised controlled study is examining the potential for video game based exercise versus traditional exercise in 80 older adults, again using the Falls Efficacy Scale as a primary outcome.22 Finally, a nascent Cochrane review will provide a comprehensive overview of the evidence for exercise interventions in fear of falling.23
What should we do in the light of the uncertainty?
Despite the many uncertainties surrounding fear of falling, little doubt exists that sustained strength and balance training in older adults improves falls risks in general, so prescription of this type of targeted exercise should be used in patients with fear of falling, particularly those who have already fallen.1 11 12 24 The efficacy of group cognitive behavioural therapy requires further investigation, and the efficacy of individual cognitive behavioural therapy is uncertain. Clinicians seeing older patients should in addition be mindful of potentially treatable anxiety and depression commonly seen in association with fear of falling.2
Recommendations for future research
Comprehensive psychosocial qualitative study examining the causative and maintaining factors for fear of falling, followed by a randomised controlled trial:
Population
Community dwelling older people with fear of falling
Interventions and comparisons
Randomised controlled trial of cognitive behavioural therapy, cognitive behavioural therapy with strength and balance training, strength and balance training alone, and usual care
Therapy to be delivered by staff not previously trained in cognitive behavioural therapy
Outcomes
Primary outcome: fear of falling as assessed by a widely validated cross cultural tool (such as the Falls Efficacy Scale International18)
Secondary outcomes: fall rates, gait, strength and balance related measures, quality of life
Health economic and process evaluations
Notes
Cite this as: BMJ 2013;346:f2933
Footnotes
This is one of a series of occasional articles that highlight areas of practice where management lacks convincing supporting evidence. The series adviser is David Tovey, editor in chief, the Cochrane Library. This paper is based on a research priority identified and commissioned by the National Institute for Health Research’s Health Technology Assessment programme on an important clinical uncertainty. To suggest a topic for this series, please email us at uncertainties{at}bmj.com.
Contributors: All three authors did the literature search, jointly wrote and revised the article, and approved the final version for publication. SWP is the guarantor.
Competing interests: All three authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; all three authors are investigators on the STRIDE study, which is funded by the National Institute for Health Research’s Health Technology Assessment programme (grant 09/70/04); no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; externally peer reviewed.