Fear of falling and restriction of mobility in elderly fallers
Bruno J. Vellas
Keywords: failing fear of falling mobility
Some elderly persons develop symptoms or behaviours in response to a fall, regardless of physical trauma [1-4]. They may express an enhanced or increased fear of falling that may result in deleterious emotional, psychological or social changes. While fear of falling is mentioned frequently as an adverse outcome of falling, little is known about it . If individuals at risk of developing fear of falling can be identified and fear of falling proves to be an independent factor in functional decline, it may be possible to target clinical interventions to prevent or alleviate this fear and its consequences in elderly patients. The purpose of this study was to identify characteristics of elderly persons who develop a fear of falling and to investigate the association of this fear with changes in self-reported physical, emotional, psychological and social well-being over time.
Subjects and methods
The Albuquerque Falls Study [5,6] is prospective investigation of falls in a cohort of elderly, community dwelling men and women that was initiated in 1990 as a adjunct to the New Mexico Aging Process Study [7,8]. The present paper reports analyses of data collected during the first 2 years of follow-up.
Entry to the study was limited to persons over 60 years of age, living independently, who had no known serious medical conditions (i.e. without diagnosed major medical conditions such as non-insulin dependent diabetes, coronary heart disease and uncontrolled hypertension). Four hundred and eighty-seven people were recruited. All subjects were volunteers and the study cohort does not represent a population-based sample. The mean age was 74 [+ or -] 6.7 years at baseline. Fifty-nine percent of the cohort were women and 41% were men. Most of the study participants were married, well-educated and more affluent than the general elderly population. The study was not limited to any ethnic group, but 96% were white, 3% Hispanic and 1% other.
For the most part, subjects’ perception of their health status was good to excellent (71.3% reported no physical disabilities or illnesses), 90% of the subjects could walk without help and could do their own shopping upon entry into the study. The mean number of prescribed drugs was 1.51 per person. The cognitive status of this population was generally good [mean Folstein’s Mini Mental State (MMSE), = 29 [+ or -] 2.1 in 1990].
Eighty-two subjects were lost to follow-up, leaving a study population of 405. Of these, 247 had one or more falls during the 2 year study period and were classified as `fallers’. Twenty-eight of the fallers did not complete follow-up assessments in 1993, leaving data for 219 subjects available for the present analyses.
All participants underwent baseline and follow-up examinations to assess physical and cognitive status and completed a self-administered questionnaire which assessed their self-reported sense of physical, emotional, psychological and social well-being. Physical health status was ascertained using a standardized medical history questionnaire and interview, and a general physical examination by a trained research nurse . Folstein’s MMSE instrument was used to assess cognitive status . Performance-based assessments of balance and gait were made using the instrument developed by Tinetti .
The Iowa Self-Assessment Inventory (ISAI) was also administered. This is a 56-item self-administered questionnaire and appears to be a reliable and valid instrument for grading self-perceived sense of well-being in population studies [11, 12]. Responses on the ISAI are subdivided into seven scales: economic resources, emotional balance, physical health, trusting others, mobility, cognitive status and social support. Scores range from 8 to 32, with higher scores indicating favourable, positive or healthy self-assessments.
The participants were instructed to report to the study co-ordinator all falls meeting the definition of “an event which results in a person coming to rest inadvertently on the ground or other lower level and other than as a consequence of the following: sustaining a violent blow; loss of consciousness; sudden onset of paralysis, as in a stroke and an epileptic seizure” . Each subject was interviewed as soon as possible after each reported fall in order to review the circumstances of the incident and determine whether the incident reported by the participant met the study definition of a fall. If the event met the study definition of a fall, a World Health Organisation falls questionnaire  was completed by the study co-ordinator while interviewing the subject via telephone. The questionnaire provides detailed information about the context and circumstances of a fall. Fear of falling was defined as a participant answering yes to the question “Are you worried about falling again?” after at least one fall in the 2 year period. To ascertain unreported falls, participants were sent stamped postcards bimonthly . If a response was not received in 15 days, a second card was sent.
Fallers who expressed fear of falling after any fall during follow-up were compared with those who did not express this fear with regard to values above or below selected cutpoints on the baseline characteristics, and logistic and multiple logistic regression methods used to estimate odds ratios ([+ or -] 95% confidence limits; OR [+ or -] 95% CI). For the ISAI subscales, the percentages in each group below the median score were compared. For balance and gait, ORs compared percentages with one or more abnormalities. Variables that were statistically significant (where OR CIs did not include 1.0) were included in a multiple logistic regression equation estimating ORs for each variable while simultaneously controlling for all other variables in the model. Numbers and percentages of subjects whose score was worse in 1993 than 1990 were compared, by fear of falling status, using a [chi square] test.
Description of falls
Seventy of the 219 subjects (32%) reported a fear of falling after at least one fall during the 2 year study period. One hundred and twenty-one of the 219 subjects (55%) reported a single fall during the 2 year study period. Twenty-six of these 121 subjects (21.5%) expressed fear of falling again subsequent to their reported fall. Of the remaining 98 subjects who had multiple falls, 54 reported no fear of falling after any fall (55%) and 31 reported fear of falling after at least one fall (32%); the remaining 13 subjects (13%) reported fear of falling after every fall. For the present analyses, the 31 subjects with multiple falls who expressed fear of falling after at least one fall were grouped with those who expressed fear of falling after all falls.
Table 1 compares subjects who expressed fear of falling after at least one fall with those who did not for baseline characteristics. Fallers who expressed fear of falling were significantly older (76.3 [+ or -] 6.6 years vs 73.6 [+ or -] 6.1 years) and somewhat more likely to be female (OR = 1.84, 95% CI 0.98 to 3.44). Fallers with one or more balance abnormalities at baseline were significantly more likely to express fear of falling (OR= 3.18, 95% CI 1.61 to 6.28), as were those who had one or more gait abnormalities (OR= 5.87,95% CI 2.80 to 12.32). In addition, fear of falling was associated significantly with the development of balance ([chi square] = 4.08, P [is less than] 0.05) and gait ([chi square] = 16.94, P [is less than] 0.001) abnormalities during follow-up in those who did not have balance or gait problems at baseline.
Table 1. Baseline characteristics in 1990 of fallers by fear of falling status (reported fear of falling after at least one fall during 1991 – 92)
Reported fear of falling
Total (n) 70 149
Age (mean and SD) 76.3 (6.6) 73.6 (6.1)(*)
Gender (female) 52 (74.3%) 91 (61.1%)
Balance (one or more abnormality) 22 (31.9%) 19 (12.8%)
Gait (one or more abnormality) 22 (31.9%) 11 (7.4%)
Mini Mental State evaluation (< 30) 43 (62.3%) 65 (43.9%)
Iowa Self-Assessment Inventory
Economic resources (< 32) 48 (66.6%) 76 (51.0%)
Emotional balance (< 28) 39 (55.7%) 75 (50.3%)
Physical health (< 27) 45 (65.2%) 67 (45.0%)
Trusting others (< 32) 36 (51.4%) 67 (45.0%)
Mobility (< 32) 41 (58.6%) 73 (49.0%)
Cognitive status (< 26) 46 (65.7%) 66 (44.3%)
Social support (< 32) 27 (38.6%) 57 (38.3%)
Crude OR(95% CI)
Age (mean and SD)
Gender (female) 1.84 (0.98, 3.44)
Balance (one or more abnormality) 3.18 (1.61, 6.28)
Gait (one or more abnormality) 5.87 (2.80, 12.32)
Mini Mental State evaluation (< 30) 2.11 (1.18, 3.78)
Iowa Self-Assessment Inventory
Economic resources (< 32) 2.10 (1.16, 3.80)
Emotional balance (< 28) 1.24 (0.70, 2.20)
Physical health (< 27) 2.30 (1.28, 4.13)
Trusting others (< 32) 1.30 (0.73, 2.29)
Mobility (< 32) 1.47 (0.83, 2.61)
Cognitive status (< 26) 2.41 (1.34, 4.32)
Social support (< 32) 1.01 (0.57, 1.82)[8.] Garry PJ, Goodwins JS, Hunt WC, Hooper EM, Leonard AG. Nutritional status in healthy elderly population: dietary and supplemental intakes. Am J Clin Nutr 1982; 36: 319-31.[9.] Folstein MF, Folstein S, McHuth PR. Mini Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189-98.[10.] Tinetti ME. Performance-oriented assessment of mobility problems in the elderly. J Am Geriatr Soc 1986; 36: 613-6.[11.] Morris WW, Buckwalter KC, Cleary TA, Gilmer JS, Hartz DL, Studer MS. Refinement of the Iowa self-assessment inventory. Gerontologist 1990; 30: 243-8.[12.] Morris WW, Buckwalter KC, Cleary TA, Gilmer JS, Andrews PH. The development and use of the Iowa Self-Assessment Inventory (ISAI). Facts Res Gerontol 1992; 6: 203-12.[13.] Vellas BJ, Baumgartner R, Wayne S, Romero L, Rubenstein L, Garry PJ. One leg standing balance is an important risk factor for injurious falls in the elderly. J Am Geriatr Soc (in press).[14.] Arfken CL, Lach HW, Birge SJ, Miller JP The prevalence and correlates of fear of falling in elderly persons living in the community. Am j Public Health 1994; 84: 565-70.[15.] Posttraumatic Stress Disorder. DSM-IV American Psychiatric Association, Washington, DC, 1994; 424-32.[16.] Murphy J, Isaacs B. The post-fall syndrome: a study of 36 elderly patients. Gerontology 1982,28: 265-70.[17.] Franzoni S, Rozzini R, Boffeli GB, Frisoni GB, Trabucchi M. Fear of falling in nursing home patients. Gerontology 1994; 40: 38-44.
Accepted 29 September 1996
Bruno J. Vellas(1,2), Sharon J. Wayne(1), Linda J. Romero(1), Richard N. Baumgartner(1), Philip J. Garry(1)
(1) Clinical Nutrition Program, Center for Population Health, University of New Mexico School of Medicine, Room 215 Surgery Building, 2701 Frontier Place NE, Albuquerque, NM 87131, USA
(2) Department of Internal Medicine and Gerontology (Professor J.-L. Albarede), World Health Organisation Collaborative Center to Promote the Safety of Aged Individuals, CHU Purpan, Toulouse, France
Address correspondence to: P. J. Garry. Fax: (+ 1) 505 272 9135
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