Protective or harmful? A qualitative exploration of older people's perceptions of worries about falling

Towards an explanation for 'unexplained' dizziness in older people

BACKGROUND

Subjective unsteadiness or dizziness, usually without increase in body sway, is common in older people. The absence of mechanistic understanding of such symptoms renders clinical management difficult. Here, we explore the mechanisms behind such idiopathic dizziness (ID), focusing on postural control abnormalities.

METHODS

Thirty patients with ID and 30 age-matched controls stood on a moving platform. Platform oscillations were randomly delivered at different velocities (from 0 to 0.2 m/s). Markers of postural control, including objective sway (trunk sway path, recorded via a sensor attached to vertebrae C7), stepping responses, subjective instability and anxiety ratings were obtained. MRI scans were available for correlations with levels of cerebral small vessel disease in 28 patients and 24 controls.

RESULTS

We observed a significant relationship between objective and subjective instability in all groups. The slope of this fit was significantly steeper for patients than controls, indicating greater perceived instability for the same body sway. Stepwise linear regression showed that the slopes of this objective-subjective instability relationship were best explained by concerns about falling (Falls Efficacy Scale-International), clinical physical functioning (Short Physical Performance Battery) and, to some degree, by neuroimaging markers of cerebral small vessel disease. In addition, patients had a reduced stepping threshold, suggesting an overly cautious postural response.

CONCLUSION

The distorted perception of instability and subtle impairments in balance control, including abnormal and overly cautious stepping responses, underlies the emergence of ID. It appears to relate to changes in postural performance, psychological functioning and disruption of postural brain networks associated with cerebral small vessel disease.

Development of Fear of Falling after proximal femoral fracture

Background: Proximal femoral fracture is common in older people. Beyond a long recovery process and significant permanent functional limitations, older people often experience subsequent Fear of Falling. The phenomenon of Fear of Falling is not fully understood; qualitative research is underrepresented but can provide insights into the experience of those affected. Objectives: We aimed to explore the experiences of Fear of Falling development and to what extent it affects peoples' life after proximal femoral fracture. Methods: We conducted semi-structured, in-depth interviews with nine older people, aged between 61 and 88, who participated in a prospective observational study. Interview data were analysed through inductive content analysis. Results: Six major themes emerged: The development of Fear of Falling; the effect of FoF and hope for recovery; alternating between moments of fear and security; fear of helplessness and of losing independence; strategies for dealing with Fear of Falling and maintaining independence; need of support by health care professionals. Conclusion: To identify and support older people in coping with Fear of Falling (after proximal femoral fracture), strategies for dealing with Fear of Falling across occupational groups and all healthcare settings should be implemented. Nurses have a key role in this process.

Prevalence and outcomes of fear of falling in older adults with falls at the emergency department: a multicentric observational study

PURPOSE

Fear of falling (FOF) may result in activity restriction and deconditioning. The aim of the study was to identify factors associated with FOF in older patients and to investigate if FOF influenced long-term outcomes.

METHODS

Multicentric, observational, prospective study including patients 65 years or older attending the emergency department (ED) after a fall. Demographical, patient- and fall-related features were recorded at the ED. FOF was assessed using a single question. The primary outcome was all-cause death. Secondary outcomes included new fall-related visit, fall-related hospitalisation, and admission to residential care. Logistic regression and Cox regression models were used for statistical analyses.

RESULTS

Overall, 1464 patients were included (47.1% with FOF), followed for a median of 6.2 years (2.2-7.9). Seven variables (age, female sex, living alone, previous falls, sedative medications, urinary incontinence, and intrinsic cause of the fall) were directly associated with FOF whereas use of walking aids and living in residential care were inversely associated. After the index episode, 748 patients (51%) died (median 3.2 years), 677 (46.2%) had a new fall-related ED visit (median 1.7 years), 251 (17.1%) were hospitalised (median 2.8 years), and 197 (19.4%) were admitted to care (median 2.1 years). FOF was associated with death (HR 1.239, 95% CI 1.073-1.431), hospitalisation (HR 1.407, 95% CI 1.097-1.806) and institutionalisation (HR 1.578, 95% CI 1.192-2.088), but significance was lost after adjustment.

CONCLUSION

FOF is a prevalent condition in older patients presenting to the ED after a fall. However, it was not associated with long-term outcomes. Future research is needed to understand the influence of FOF in maintenance of functional capacity or quality of life.

Perspectives and experiences of community-dwelling older adults who experience falling: A qualitative meta-synthesis

Objectives

This study aimed to systematically review and synthesize the perspectives and experiences of community-dwelling older adults who experience falling, to inform the subsequent development of fall prevention and management interventions, and to provide recommendations for healthcare policy and practice.

Methods

The review was a qualitative meta-aggregation study following the JBI qualitative systematic review methodology. Databases searched included Medline (through PubMed), CINAHL, PsycINFO, Embase, and the Web of Science. Peer-reviewed articles published in the English language from January 2010 to May 2023 were retrieved. The JBI Qualitative Assessment and Review Instrument (JBI-QARI) was used to assess the quality of the methodology. The ConQual ranking system was used to establish confidence in the synthesized findings. The protocol was registered with PROSPERO (CRD 42023421789).

Results

This review included ten qualitative studies with an overall quality score of 60%-90%. Data extracted from eligible studies resulted in 59 findings, which were then aggregated into seven categories based on the similarity in meaning. Three synthesized findings were generated and rated as moderate for synthesized finding 2 and low for synthesized finding 1 and 3 on the ConQual score. Synthesized finding 1: Older adults experience physical injuries and pain, restricted daily activities, and limitations in social activities, reduction or loss of in independence, and have feelings of fear and helplessness. Synthesized finding 2: After experiencing a fall, older adults reflect on the cause of the fall and recognize and interpret the risk factors. Synthesized finding 3: Older adults' reflections on the causes and impact of falls reveal both positive and negative reactions. They perceive a number of strategies for coping with falls and their consequences, such as using assistive devices, correcting risk factors, seeking medical help, and receiving ongoing physical and psychological attention.

Conclusions

Healthcare providers should pay attention to the feelings and experiences of older adults after falling, as well as their reflection on the causes and impacts of falling, and develop tailored plans for intervention. There is also a need for longitudinal studies to examine the longer-term impact of falls on older adults to provide insights into the stability and changes in their reflections, perceptions, attitudes, and preventive behaviors over time.

Physical-activity interventions to reduce fear of falling in frail and pre-frail older adults: a systematic review of randomized controlled trials

BACKGROUND

Frailty in older adults leads to progressive deterioration of their physical condition and makes them prone to develop Fear of Falling (FoF). Physical-activity interventions appear to be effective in managing the components of frailty but there is no clear evidence to determine whether physical-activity may affect FoF in frail and pre-frail older adults.

OBJECTIVE

Τhis systematic literature review aims to synthesize evidence on the relationship between the physical interventions to ameliorate balance, strength, and mobility and FoF reduction in frail and pre-frail older adults.

METHODS

Studies assessing physical-activity interventions for frail and pre-frail older adults aged 60 years and older were identified in English through searches in PubMed, ScienceDirect, and Cochrane Central Register of Controlled Trials databases till February 2023. Study quality was assessed, and a qualitative synthesis of results was performed.

RESULTS

A total of 13 studies published were included. All of them were Randomized Control Trials and the most frequent assessment tool used to assess FoF (10 of 13 studies) was the Fall Efficacy Scale-International (FES-I). Six studies were assessed as having a low risk of bias. Cumulatively, the findings of this review indicate that physical-activity interventions are effective in reducing the FoF of frail and pre-frail older adults.

CONCLUSION

The results are encouraging and recapitulate the positive role of physical interventions in FoF reduction. However, future research would benefit from longer follow-up periods, longer intervention duration, and participation of interdisciplinary teams.

The influence of fear of falling on the control of upright stance across the lifespan

BACKGROUND

Standing at height, and subsequent changes in emotional state (e.g., fear of falling), lead to robust alterations in balance in adults. However, little is known about how height-induced postural threat affects balance performance in children. Children may lack the cognitive capability necessary to inhibit the processing of threat and fear-related stimuli, and as a result, may show more marked (and perhaps detrimental) changes in postural control compared to adults. This work explored the emotional and balance responses to standing at height in children, and compared responses to young and older adults.

METHODS

Children (age: 9.7 ± 0.8 years, n = 38), young adults (age: 21.8 ± 4.0 years, n = 45) and older adults (age: 73.3 ± 5.0 years, n = 15) stood in bipedal stance in two conditions: at ground level and 80 cm above ground. Centre of pressure (COP) amplitude (RMS), frequency (MPF) and complexity (sample entropy) were calculated to infer postural performance and strategy. Emotional responses were quantified by assessing balance confidence, fear of falling and perceived instability.

RESULTS

Young and older adults demonstrated a postural adaptation characterised by increased frequency and decreased amplitude of the COP, in conjunction with increased COP complexity (sample entropy). In contrast, children demonstrated opposite patterns of changes: they exhibited an increase in COP amplitude and decrease in both frequency and complexity when standing at height.

SIGNIFICANCE

Children and adults adopted different postural control strategies when standing at height. Whilst young and older adults exhibited a potentially protective "stiffening" response to a height-induced threat, children demonstrated a potentially maladaptive and ineffective postural adaptation strategy. These observations expand upon existing postural threat related research in adults, providing important new insight into understanding how children respond to standing in a hazardous situation.

Protocol of a 12-week eHealth programme designed to reduce concerns about falling in community-living older people: Own Your Balance randomised controlled trial

INTRODUCTION

Concerns about falling (CaF) are common in older people and have been associated with avoidance of activities of daily life. Exercise designed to prevent falls can reduce CaF, but the effects are usually short-lived. Cognitive behavioural therapy (CBT) can reduce CaF for longer but is not readily available in the community and unlikely to prevent falls. A multidomain intervention that combines CBT, motivational interviewing and exercise could be the long-term solution to treat CaF and reduce falls in older people with CaF. This paper describes the design of a randomised controlled trial to test the effectiveness of two different 12 week self-managed eHealth programmes to reduce CaF compared with an active control.

METHODS

A total of 246 participants (82 per group) aged 65 and over, with substantial concerns about falls or balance will be recruited from the community. They will be randomised into: (1) myCompass-Own Your Balance (OYB) (online CBT programme) intervention or (2) myCompass-OYB plus StandingTall intervention (an eHealth balance exercise programme), both including motivational interviewing and online health education or (3) an active control group (online health education alone). The primary outcome is change in CaF over 12 months from baseline of both intervention groups compared with control. The secondary outcomes at 2, 6 and 12 months include balance confidence, physical activity, habitual daily activity, enjoyment of physical activity, social activity, exercise self-efficacy, rate of falls, falls health literacy, mood, psychological well-being, quality of life, exercise self-efficacy, programme adherence, healthcare use, user experience and attitudes towards the programme. An intention-to-treat analysis will be applied. The healthcare funder's perspective will be adopted for the economic evaluation if appropriate.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the South Eastern Sydney Local Health District Human Research Ethics Committee (2019/ETH12840). Results will be disseminated via peer-reviewed journals, local and international conferences, community events and media releases.

TRIAL REGISTRATION NUMBER

ACTRN12621000440820.

Fear-related visual stimuli do not promote internal focus of attention in older adults

BACKGROUND

The influence of internal focus (IF) on postural balance needs to be determined when assessing fall risk in older adults. Moreover, the mechanism through which IF is triggered should be elucidated.

RESEARCH QUESTION

Does fear unrelated to threats to postural balance modulate IF during postural control?

METHODS

The participants were 16 community-dwelling older adults. We generated visual stimuli for neutral and fear conditions using the International Affective Picture System. Participants were assessed for postural control while standing on a stabilometer and looking at projected images. The IF allocated to postural control during task was assessed immediately after the task using the Conscious Movement Processing subscale of the Movement-Specific Reinvestment Scale (MSRS-CMP). Sympathetic activity was assessed using the mean low-frequency/high-frequency ratio (LF/HF), and posture was evaluated using the root mean square area (RMS-A), anteroposterior mean power frequency (MPF-AP), mediolateral MPF, and co-contraction index. Differences (Δ) in the MSRS-CMP, RMS-A and MPF between the neutral/fear conditions and control condition were calculated. Each index was also compared among the control, neutral, and fear conditions. The correlations between ΔMSRS-CMP and postural measures were evaluated. Equivalence tests were conducted to determine whether change of IF was different among conditions.

RESULTS

The MSRS-CMP score did not differ significantly among conditions; equivalence was observed. The LF/HF and MPF-AP in the fear condition were higher than in the other conditions. The RMS-A in the fear condition was lower than in the neutral condition. ΔMSRS-CMP and ΔMPF-AP were significantly negatively correlated.

SIGNIFICANCE

The results of this study suggest that feelings of fear affect postural control but not the IF of attention. Taken together with previous research, the findings of this study suggest that consideration of the fear-inducing context may be useful in assessments of, and interventions for, older adults with a fall risk.

Association Between Concerns About Falling and Risk of Injurious Falls in Older Adults: The Role of Balance Impairment

OBJECTIVES

We aimed to examine the extent to which concerns about falling are associated with the risk of injurious falls in older adults, and to explore the role of balance impairment in this association.

DESIGN

Prospective study with a 5-year follow-up.

SETTING AND PARTICIPANTS

Participants were 1281 people, aged ≥60 years (62.5% women), from the Swedish National Study on Aging and Care in Kungsholmen.

METHODS

Data on injurious falls during 5 years of follow-up was obtained from national registers. Cox and Laplace regression models were applied to examine injurious falls in relation to concerns about falling (binary variable), balance impairment (one-leg balance test), or an indicator variable with 4 mutually exclusive categories based on the presence of concerns about falling and balance impairment.

RESULTS

There was no statistically significant association between concerns about falling and injurious falls in the total sample when adjusting for covariates. We found significant interactions of concerns about falling with balance impairment and age (<70 vs ≥80 years), so that the association between concerns about falling and injurious falls was more evident in people with better balance and the younger-old participants (P < .05). Having only concerns about falling [hazard ratio (HR) 2.06, 95% CI 1.22, 3.48], only balance impairment (HR 2.22, 95% CI 1.38, 3.56), or both (HR 2.35, 95% CI 1.45, 3.82) were associated with an increased risk of injurious falls compared to those with neither concerns about falling nor balance impairment.

CONCLUSIONS AND IMPLICATIONS

Our results suggest that concerns about falling may increase the risk of injurious falls, especially among younger-old people or those without objective balance impairment.

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

BACKGROUND

Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour.

OBJECTIVES

To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies.

SELECTION CRITERIA

This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition.

DATA COLLECTION AND ANALYSIS

Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions.

AUTHORS' CONCLUSIONS

CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

The genetics of falling susceptibility and identification of causal risk factors

Falls represent a huge health and economic burden. Whilst many factors are associated with fall risk (e.g. obesity and physical inactivity) there is limited evidence for the causal role of these risk factors. Here, we used hospital and general practitioner records in UK Biobank, deriving a balance specific fall phenotype in 20,789 cases and 180,658 controls, performed a Genome Wide Association Study (GWAS) and used Mendelian Randomisation (MR) to test causal pathways. GWAS indicated a small but significant SNP-based heritability (4.4%), identifying one variant (rs429358) in APOE at genome-wide significance (P < 5e-8). MR provided evidence for a causal role of higher BMI on higher fall risk even in the absence of adverse metabolic consequences. Depression and neuroticism predicted higher risk of falling, whilst higher hand grip strength and physical activity were protective. Our findings suggest promoting lower BMI, higher physical activity as well as psychological health is likely to reduce falls.

A concept analysis of fear of falling in older adults: insights from qualitative research studies

BACKGROUND

Fear of falling is a persistent concern about falls that commonly occur in older adults. Recently, it has been argued that fear of falling doesn't simply mean a state of low falls efficacy, but is a concept distinct from falls efficacy. However, the two concepts are still indistinguishable. Therefore, it is necessary to understand the unique characteristics of the fear of falling. This study aims to analyze the concept of 'fear of falling' faced by older adults.

METHODS

This study is designed as a concept analysis. A concept analysis was conducted by Walker & Avant's eight-step concept analysis method. A total of 16 pieces of literature were selected by inclusion and exclusion criteria from those published in Pubmed and Scopus between 1993 and 2022 on 8 November 2022.

RESULTS

Two antecedents, four attributes, and five consequences were identified. Apprehension caused by the unpredictable nature of falls, unease related to one's vulnerability, high vigilance-related to the environment, and concern about potential harm after fall events were presented as attributes of fear of falling in older adults. There were two antecedents of fear of falling which were awareness of falls and near falls, and direct/indirect experience about falls and near falls. As consequences of fear of falling, protective effect, activities curtailment, reduction in radius of living, restricted freedom, and limited social activities were reported.

CONCLUSION

It was confirmed that falls and the fear-inducing process were fused to constitute the unique characteristics of the fear of falling. This can be presented as an important basis for future research on the fear of falling or dealing with various aspects of the fear of falling in the clinical field.

Relationship between fear of falling and fall risk among older patients with stroke: a structural equation modeling

BACKGROUND

With reduced balance and mobility, older patients with stroke are more susceptible to fear of falling (FOF). A maladaptive form of FOF can cause excessive activity restriction, poor balance, and recurrent falls, forming a self-reinforcing vicious cycle. This study applied and adapted the FOF model to investigate the interaction between FOF and fall risk in older stroke patients.

METHODS

A cross-sectional study was conducted among 302 older stroke patients aged 60 and over. All participants were invited to complete the FOF, fall risk, physical activity, and balance tests, which were measured by the Falls Efficacy Scale International (FES-I), Self-Rated Fall Risk Questionnaire (FRQ), the long-form International Physical Activity Questionnaire (IPAQ-LF) and the Four-Stage Balance Test (FSBT) respectively. Data were analyzed using structural equation modeling.

RESULTS

The mean age of the respondents was 68.62 ± 7.62 years; 8.94% reported a high level of FOF, and 18.21% reported a moderate level of FOF. The structural equation model showed that FOF was directly associated with fall risk (β=-0.38, p < 0.001), and was indirectly associated with fall risk via physical activity (β=-0.075, p < 0.05) and balance ability (β=-0.123, p < 0.05). Depression (β=-0.47, p < 0.001), fall history (β=-0.13, p < 0.05), and female sex (β=-0.16, p < 0.05) affected FOF, while anxiety was not associated with FOF.

CONCLUSIONS

The increased risk of falling in older stroke patients results from a maladaptive FOF affected by depression, fall history, poor balance ability, and limited physical activity. Our results suggest that greater attention should be paid to FOF during stroke recovery and fall prevention. A multifaced intervention program encompassing physiological and psychological factors should be designed to address FOF and prevent falls.

Association Between Pain and Fall Worry Among Community-Dwelling Older People With Cognitive Impairment in the United States

Background and Objectives

Previous studies have found that pain is associated with fall worry among community-dwelling older people. However, both pain and fall worry are poorly understood and underaddressed among community-dwelling older people with cognitive impairment (CI). It is essential to examine the association between pain and fall worry, and how sociodemographic and health characteristics may shape fall worry among this subgroup.

Research Design and Methods

We used data from the 2015 National Health and Aging Trends Study (analytic sample: n = 1150 community-dwelling older people with CI; were self-interviewed; mean age: 81; age range: 65-107). The number of pain sites in the prior month was assessed by presenting a card listing common pain sites (eg, back, knees). Two questions assessed past-month fall worry, "did you worry about falling down" and "did this worry ever limit your activities." Following descriptive statistics, we fit multinomial logistic regression models to examine the associations between different pain characteristics (number of sites, severity, location) and non-activity-limiting and activity-limiting fall worry.

Results

Non-activity-limiting fall worry was endorsed by 21.1% and activity-limiting fall worry by 13.6% of community-dwelling older people with CI. After adjusting for sociodemographic characteristics and fall-worry-related covariates, multinomial logistic regression analysis found that a greater number of pain sites (relative risk ratio [RRR] = 1.22, 95% Confidence Interval [95% CI] = 1.12-1.33, p <.001) and severe pain (RRR = 2.05, 95% CI = 1.12-3.75, p = .020) was associated with activity-limiting fall worry. Both lower body (knee, foot, and leg) and upper body (hand, wrist, shoulder, neck, and stomach) pain were found to be associated with a high risk of activity-limiting fall worry.

Discussion and Implications

These findings suggest pain and fall worry are common among community-dwelling older people with CI and can be elicited directly from those who are communicative. Fall prevention for this population should prioritize pain management to mitigate activity-limiting fall worry because activity limitation increases the risk of falls.

Effects of early mental state changes on physical functions in elderly patients with a history of falls

BACKGROUND

Fear of falling is a potential consequence for older adults who have experienced a fall. Whether such psychological concerns related to falls, in turn, affect physical function? Especially those who have a history of falling but have not been diagnosed with anxiety, depression, or both. This study aimed to clarify the effects of early psychological changes on the physical function of older patients.

METHODS

The 111 participants with falling history were divided into the poor physical function (PPF) group with the Short Physical Performance Battery (SPPB) ≤ 9 and the good physical function (GPF) group with SPPB > 9. Their physical function was assessed through 4-m gait speed (4MGS), five times sit-to-stand test (FTSST), grip strength, and Timed Up and Go tests TUGT. Their mental state was assessed by the self-rating anxiety/depression scale (SAS/SDS).

RESULTS

(1) SAS/SDS scores were negatively correlated with the SPPB score, gait speed, and maximum grip strength (males). (2) Multivariate logistic regression analysis showed that the SPPB score was subject to such independent influence factors: cerebrovascular disease (OR = 11.805; P = 0.005), normal ratio of grip strength (OR = 0.046; P = 0.016), TUGT (OR = 1.717; P < 0.001), and SDS score (OR = 1.154; P = 0.008). (3) The area under the ROC curve was 0.699 (0.601, 0.797) for SAS score, with a sensitivity of 0.776 and a specificity of 0.547; the AUC was 0.694 (0.596, 0.792) for SDS score, with a sensitivity of 0.586 and a specificity of 0.755.

CONCLUSIONS

In older adults with a history of falls without a diagnosis of anxiety or depression, higher SAS/SDS scores were associated with worse fall-related physical function, and there was a statistically significant correlation between the two. This may indicate a risk of falling again in the future.

Overcoming waves of helplessness: The meaning of experiencing fear of falling

Fear of falling (FOF) is prevalent among older adults. While the phenomenon has been conceptually defined and the factors associated with FOF are evident in the nursing literature, the deeply personal experience of this fear from the perspective of older adults is often overlooked. The aim of this study was to explore the meaning of experiencing FOF among older adults (N = 4). Each participant was interviewed twice using van Manen's interpretive phenomenological methodology. Four major interpretive themes emerged: Loss of Self, Part of my Existence, Remaining Safe Within the Boundaries of Fear, and The Exhausting Appraisal of Relationships. While the older adults struggled to manage their FOF, a deeper meaning was expressed during a relentless striving for self-preservation. While FOF can be an experience of overwhelming helplessness, the older adults in this study demonstrated personal resiliency, a perspective that is often lacking in the current literature.

The perceived control model of falling: developing a unified framework to understand and assess maladaptive fear of falling

BACKGROUND

fear of falling is common in older adults and can have a profound influence on a variety of behaviours that increase fall risk. However, fear of falling can also have potentially positive outcomes for certain individuals. Without progressing our understanding of mechanisms underlying these contrasting outcomes, it is difficult to clinically manage fear of falling.

METHODS

this paper first summarises recent findings on the topic of fear of falling, balance and fall risk-including work highlighting the protective effects of fear. Specific focus is placed on describing how fear of falling influences perceptual, cognitive and motor process in ways that might either increase or reduce fall risk. Finally, it reports the development and validation of a new clinical tool that can be used to assess the maladaptive components of fear of falling.

RESULTS

we present a new conceptual framework-the Perceived Control Model of Falling-that describes specific mechanisms through which fear of falling can influence fall risk. The key conceptual advance is the identification of perceived control over situations that threaten one's balance as the crucial factor mediating the relationship between fear and increased fall risk. The new 4-item scale that we develop-the Updated Perceived Control over Falling Scale (UP-COF)-is a valid and reliable tool to clinically assess perceived control.

CONCLUSION

this new conceptualisation and tool (UP-COF) allows clinicians to identify individuals for whom fear of falling is likely to increase fall risk, and target specific underlying maladaptive processes such as low perceived control.

The use of the World Guidelines for Falls Prevention and Management's risk stratification algorithm in predicting falls in The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

the aim of this study was to retrospectively operationalise the World Guidelines for Falls Prevention and Management (WGFPM) falls risk stratification algorithm using data from The Irish Longitudinal Study on Ageing (TILDA). We described how easy the algorithm was to operationalise in TILDA and determined its utility in predicting falls in this population.

METHODS

participants aged ≥50 years were stratified as 'low risk', 'intermediate' or 'high risk' as per WGFPM stratification based on their Wave 1 TILDA assessments. Groups were compared for number of falls, number of people who experienced one or more falls and number of people who experienced an injury when falling between Wave 1 and Wave 2 (approximately 2 years).

RESULTS

5,882 participants were included in the study; 4,521, 42 and 1,309 were classified as low, intermediate and high risk, respectively, and 10 participants could not be categorised due to missing data. At Wave 2, 17.4%, 43.8% and 40.5% of low-, intermediate- and high-risk groups reported having fallen, and 7.1%, 18.8% and 18.7%, respectively, reported having sustained an injury from falling.

CONCLUSION

the implementation of the WGFPM risk assessment algorithm was feasible in TILDA and successfully differentiated those at greater risk of falling. The high number of participants classified in the low-risk group and lack of differences between the intermediate and high-risk groups may be related to the non-clinical nature of the TILDA sample, and further study in other samples is warranted.

Engaging community-dwelling older adults in fall prevention programs: a qualitative study on strategies promoting participation in fall prevention programs among community-dwelling older adults

Introduction

Fall rates and fall-related injuries among community-dwelling older adults (≥65 years) are expected to increase rapidly, due to the aging population worldwide. Fall prevention programs (FPPs), consisting of strength and balance exercises, have been proven effective in reducing fall rates among older adults. However, these FPPs have not reached their full potential as most programs are under-enrolled. Therefore, this study aims to identify promising strategies that promote participation in FPPs among community-dwelling older adults.

Methods

This is an exploratory qualitative study. Previously, barriers and facilitators for participation in FPPs by older adults had been identified. Next, six strategies had been designed using the Intervention Mapping approach: (1) reframing; (2) informing about benefits; (3) raising awareness of risks; (4) involving social environment; (5) offering tailored intervention; (6) arranging practicalities. Strategies were validated during semi-structured interviews with community-dwelling older adults (n = 12) at risk of falling. Interviews were audio-recorded, transcribed, and analyzed following a qualitative thematic methodology, with a hybrid approach.

Results

All strategies were considered important by at least some of the respondents. However, two strategies stood out: (1) reframing 'aging' and 'fall prevention': respondents preferred to be approached differently, taking a 'life course' perspective about falls, and avoiding confronting words; and (2) 'informing about benefits' (e.g., 'living independently for longer'); which was mentioned to improve the understanding of the relevance of participating in FPPs. Other strategies were considered important to take into account too, but opinions varied more strongly.

Discussion

This study provides insight into potential strategies to stimulate older adults to participate in FPPs. Results suggest that reframing 'aging' and 'fall prevention' may facilitate the dialogue about fall prevention, by communicating differently about the topic, for example 'staying fit and healthy', while focusing on the benefits of participating in FPPs. Gaining insight into the strategies' effectiveness and working mechanisms is an area for future research. This could lead to practical recommendations and help professionals to enhance older adults' participation in FPPs. Currently, the strategies are further developed to be applied and evaluated for effectiveness in multiple field labs in a central Dutch region (Utrecht).

The effect of mobility-related anxiety on walking across the lifespan: a virtual reality simulation study

Older adults who report a fear of falling are more likely to subsequently fall, yet, some gait anxiety-related alterations may protect balance. We examined the effect of age on walking in anxiety-inducing virtual reality (VR) settings. We predicted a high elevation-related postural threat would impair gait in older age, and differences in cognitive and physical function would relate to the observed effects. Altogether, 24 adults (age (y) = 49.2 (18.7), 13 women) walked on a 2.2-m walkway at self-selected and fast speeds at low (ground) and high (15 m) VR elevation. Self-reported cognitive and somatic anxiety and mental effort were greater at high elevations (all p < 0.001), but age- and speed-related effects were not observed. At high VR elevations, participants walked slower, took shorter steps, and reduced turning speed (all p < 0.001). Significant interactions with age in gait speed and step length showed that relatively older adults walked slower (β = - 0.05, p = 0.024) and took shorter steps (β = - 0.05, p = 0.001) at self-selected speeds at high compared to low elevation settings. The effect of Age on gait speed and step length disappeared between self-selected and fast speeds and at high elevation. At self-selected speeds, older adults took shorter and slower steps at high elevation without changing step width, suggesting that in threatening settings relatively older people change gait parameters to promote stability. At fast speeds, older adults walked like relatively younger adults (or young adults walked like older adults) supporting the notion that people opt to walk faster in a way that still protects balance and stability in threatening settings.

Why should clinical practitioners ask about their patients' concerns about falling?

Concerns (or 'fears') about falling (CaF) are common in older adults. As part of the 'World Falls Guidelines Working Group on Concerns about Falling', we recommended that clinicians working in falls prevention services should regularly assess CaF. Here, we expand upon these recommendations and argue that CaF can be both 'adaptive' and 'maladaptive' with respect to falls risk. On the one hand, high CaF can lead to overly cautious or hypervigilant behaviours that increase the risk of falling, and may also cause undue activity restriction ('maladaptive CaF'). But concerns can also encourage individuals to make appropriate modifications to their behaviour to maximise safety ('adaptive CaF'). We discuss this paradox and argue that high CaF-irrespective of whether 'adaptive' or 'maladaptive'-should be considered an indication that 'something is not right', and that is represents an opportunity for clinical engagement. We also highlight how CaF can be maladaptive in terms of inappropriately high confidence about one's balance. We present different routes for clinical intervention based on the types of concerns disclosed.

From fear of falling to choking under pressure: A predictive processing perspective of disrupted motor control under anxiety

Under the Predictive Processing Framework, perception is guided by internal models that map the probabilistic relationship between sensory states and their causes. Predictive processing has contributed to a new understanding of both emotional states and motor control but is yet to be fully applied to their interaction during the breakdown of motor movements under heightened anxiety or threat. We bring together literature on anxiety and motor control to propose that predictive processing provides a unifying principle for understanding motor breakdowns as a disruption to the neuromodulatory control mechanisms that regulate the interactions of top-down predictions and bottom-up sensory signals. We illustrate this account using examples from disrupted balance and gait in populations who are anxious/fearful of falling, as well as 'choking' in elite sport. This approach can explain both rigid and inflexible movement strategies, as well as highly variable and imprecise action and conscious movement processing, and may also unite the apparently opposing self-focus and distraction approaches to choking. We generate predictions to guide future work and propose practical recommendations.

Frailty, falls and poor functional mobility predict new onset of activity restriction due to concerns about falling in older adults: a prospective 12-month cohort study

PURPOSE

Concerns about falling are common in older adults and often cause activity restriction. This can lead to physical deconditioning, falls and social isolation. However, not every concerned older adult will restrict their activities. This 12-month longitudinal study investigated the physical and psychosocial factors that predict the new onset of activity restriction due to concerns about falling in older people.

METHODS

Participants were 543 older adults (M_age = 80.3 ± 4.4 years, range: 75-98) who did not report activity restriction due to concerns about falling at Timepoint-1 (negative response to the following question: "Do concerns about falling stop you going out-and-about?"). Participants completed a battery of physical and psychological assessments at Timepoint-1. Using binary logistic regression, we then assessed which of these variables predicted whether participants reported having started restricting their activity due to concerns about falling at the 12-month follow-up (Timepoint 2).

RESULTS

10.1% of the sample started to restrict activity due to concerns about falling at Timepoint 2. Three key predictors significantly predicted activity restriction group status at 12-month follow-up: greater frailty at Timepoint-1 (Fried Frailty Index; OR = 1.58, 95% CI 1.09-2.30), experiencing a fall between Timepoint-1 and 2 (OR = 2.22, 95% CI 1.13-4.38) and poorer functional mobility at Timepoint-1 (Timed up and Go; OR = 1.08, 95% CI 1.01-1.15).

CONCLUSIONS

Frailty, experiencing a fall and poorer functional mobility all predicted the onset of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of activity restriction due to concerns about falling.

How to tackle the global challenge of falls?

Worldwide, falls and accompanying injuries are increasingly common, making their prevention and management a critical global challenge. The wealth of evidence to support interventions to prevent falls has recently (2022) been distilled in the first World Falls Guideline for Prevention and Management for Older Adults. The core of falls prevention includes (i) risk assessment and stratification; (ii) general recommendations on optimising physical function and mobility for all and (iii) offering a holistic, multidomain intervention to older adults at high risk of falls, in which the older adult's priorities, beliefs and resources are carefully considered. In recent decades, sustainable and adequately resourced falls prevention has proved challenging, although evidence suggests that suboptimal implementation of falls prevention is ineffective. Future research should focus on understanding the most successful approaches for implementation. To further optimise falls prevention, recent developments include technological innovation to identify and prevent falls, including exergaming. Further work is warranted to understand how to best incorporate the concepts of frailty and sarcopenia in falls prevention and management. This themed collection includes key articles in the field of falls prevention, covering several topics including risk factors, effective interventions, older adult's views, implementation issues and future perspectives.

A Protection Motivation Theory Approach to Understanding How Fear of Falling Affects Physical Activity Determinants in Older Adults

OBJECTIVES

This study applied an extended Protection Motivation Theory to investigate the relative importance of fear of falling (FoF) among motivational and intentional determinants of physical activity (PA) behavior.

METHODS

Older U.S. adults (N = 667, 65+) were surveyed using online research panels and completed measures of self-efficacy and response efficacy (coping appraisal), perceived vulnerability and perceived severity (threat appraisal), FoF, autonomous motivation, intention, physical health, and past PA level.

RESULTS

Our structural equation model showed that past PA level and health predicted intention via cognitive constructs. PA and health predicted FoF and motivation via threat and coping appraisal. FoF did not directly predict intention.

DISCUSSION

Results from this sample provide support for the predictive effects of threat appraisal on fear. However, findings suggest that FoF may not be of great importance for the formation of PA intention compared with an established habit of being physically active and a subsequently fostered coping appraisal and motivation.