Fear of Falling in the Elderly
Nadine Gagnon, MD, FRCP(C), Research Fellow, Department of Psychiatry, University of Toronto and University Health Network, and Toronto Rehabilitation Institute, Toronto, ON.
Alastair J. Flint, MB, ChB, FRCP(C), FRANZCP, Professor of Psychiatry, University of Toronto, and Head, Geriatric Psychiatry Program, University Health Network, Toronto, ON.
To date, researchers have addressed many aspects of falling. During the past two decades, there has been increasing interest in the phenomenon of fear of falling. This paper summarizes data pertaining to the epidemiology, assessment and management of fear of falling, as well as the relationship of fear of falling to other factors.
Key words: fear of falling, elderly, epidemiology, self-efficacy, activities of daily living.
Evolution of the Concept
In the late 1970s, Marks and Bebbington described "space phobia" in four elderly women who had intense fear of falling "when there was no visible support at hand or on seeing space cues while driving".1 These authors speculated that space phobia "might be a hitherto unrecognized syndrome or an unusual variant of agoraphobia". In 1982, Murphy and Isaacs published their classic article on "post-fall syndrome" in which elderly people who had fallen developed severe anxiety that affected their ability to stand and walk unsupported.2 Subsequent research demonstrated that elderly people can develop fear of falling even when they have not fallen.3-5 Over the years, various definitions of fear of falling have evolved. Some authors have focused purely on the fear,6 while others have included avoidance of activities as a consequence of the fear.7 A few authors have eschewed the term "fear" and have instead focused on the person's loss of confidence in balance and walking.8,9
Epidemiology
Community-based epidemiologic studies have found that 21-61%3,6-8,10,11 of elderly people experience some degree of fear of falling. Community studies that are limited to elderly people who have actually fallen have reported prevalence rates of 32-83%.12,13 Strikingly, 33-46% of community-dwelling elders who have not fallen also report fear of falling.3,4 Among selected populations, fear of falling has been found among 46% of nursing home residents,14 47% of persons attending a dizziness clinic,15 66% of patients on a rehabilitation ward,16 and 30% of hospitalized elderly patients without a specific diagnosis (40% of those who had fallen and 23% of those who had not fallen).17 Some of these prevalence rates may actually be underestimates, since people who are most fearful may be less likely to participate in research studies.
Among elderly persons who are afraid of falling, up to 70%3,7,8,10,16 acknowledge avoiding activities because of this fear. In some cases, individuals become housebound as a result of their fear. Activity restriction is, in itself, a risk factor for falls because it can lead to muscle atrophy, deconditioning and poorer balance.4,12 Curtailment of activities can also lead to social isolation.18 Thus, fear of falling can contribute to both functional decline and impaired quality of life.
Assessment Tools
Several approaches to the assessment and measurement of fear of falling have been used and may partly explain the variability in the prevalence rates reported above. The simplest approach has been to ask subjects the following question: "Are you afraid of falling?". An extension of this categorical approach is to rate the severity of fear, ranging, for example, from mildly, moderately or very afraid.
Although a direct question is simple, straightforward and easily generates prevalence estimates, this approach lacks the sensitivity of a continuous measure. Tinetti and colleagues operationalized fear of falling as low perceived self-efficacy. Self-efficacy refers to an individual's perception of capabilities within a particular domain of activities.19 Tinetti, et al. developed the Falls Efficacy