Fear of falling and restriction of mobility in elderly fallers

Age and Ageing,  May, 1997  by Bruno J. Vellas,  Sharon J. Wayne,  Linda J. Romero,  Richard N. Baumgartner,  Philip J. Garry

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Keywords: failing fear of falling mobility

Introduction

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 [2]. 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 [8]. Folstein's MMSE instrument was used to assess cognitive status [9]. Performance-based assessments of balance and gait were made using the instrument developed by Tinetti [10].

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" [5]. 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 [5] 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 [5]. If a response was not received in 15 days, a second card was sent.