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www.geriatricsandaging.ca 15
Fear of Falling in the Elderly
Evolution of the ConceptIn the late 1970s, Marks and
Bebbingtondescribed space phobia in four elderlywomen who had
intense fear of fallingwhen there was no visible support athand or
on seeing space cues while driv-ing.1 These authors speculated
thatspace phobia might be a hitherto unrec-ognized syndrome or an
unusual variantof agoraphobia. In 1982, Murphy andIsaacs published
their classic article onpost-fall syndrome in which elderlypeople
who had fallen developed severeanxiety that affected their ability
to standand walk unsupported.2 Subsequentresearch demonstrated that
elderly peo-ple can develop fear of falling even whenthey have not
fallen.3-5 Over the years,various definitions of fear of falling
haveevolved. Some authors have focusedpurely on the fear,6 while
others haveincluded avoidance of activities as a con-sequence of
the fear.7 Afew authors haveeschewed the term fear and haveinstead
focused on the persons loss ofconfidence in balance and
walking.8,9
EpidemiologyCommunity-based epidemiologic stud-ies have found
that 2161%3,6-8,10,11 of eld-erly people experience some degree
offear of falling. Community studies thatare limited to elderly
people who haveactually fallen have reported prevalence
rates of 3283%.12,13 Strikingly, 3346% ofcommunity-dwelling
elders who havenot fallen also report fear of falling.3,4
Among selected populations, fear offalling has been found among
46% ofnursing home residents,14 47% of personsattending a dizziness
clinic,15 66% ofpatients on a rehabilitation ward,16 and30% of
hospitalized elderly patients with-out a specific diagnosis (40% of
thosewho had fallen and 23% of those whohad not fallen).17 Some of
these preva-lence rates may actually be underesti-mates, since
people who are most fearfulmay be less likely to participate
inresearch studies.
Among elderly persons who areafraid of falling, up to
70%3,7,8,10,16
acknowledge avoiding activities becauseof this fear. In some
cases, individualsbecome housebound as a result of theirfear.
Activity restriction is, in itself, a riskfactor for falls because
it can lead to mus-cle atrophy, deconditioning and
poorerbalance.4,12 Curtailment of activities canalso lead to social
isolation.18 Thus, fearof falling can contribute to both
func-tional decline and impaired quality of life.
Assessment ToolsSeveral approaches to the assessmentand
measurement of fear of falling havebeen used and may partly explain
thevariability in the prevalence rates report-
ed above. The simplest approach hasbeen to ask subjects the
following ques-tion: Are you afraid of falling?. Anextension of
this categorical approach isto rate the severity of fear, ranging,
forexample, from mildly, moderately orvery afraid.
Although a direct question is sim-ple, straightforward and
easily gener-ates prevalence estimates, this approachlacks the
sensitivity of a continuousmeasure. Tinetti and colleagues
opera-tionalized fear of falling as low per-ceived self-efficacy.
Self-efficacy refersto an individuals perception of capa-bilities
within a particular domain ofactivities.19 Tinetti, et al.
developed theFalls Efficacy Scale (FES), a 10-questionself-rated
scale assessing a persons con-fidence in performing activities in
thehome (e.g., How confident are you thatyou can take a bath or a
shower withoutfalling?).8 The subject rates each ques-tion from 1
to 10, resulting in a summa-tive global score whereby a higher
scoreis reflective of lower confidence. Thescale has been modified
for patientswith strokes [FES(S)]20 and to includeoutdoor
activities (MFES).9
In 1995, Powell and Myers devel-oped the Activities-specific
Balance Con-fidence Scale (ABC), also based on theself-efficacy
concept.21 This 16-item scalecontains a broader range of activity
diffi-culty and more detailed activity descrip-tors than the FES.
It has greater reliabilitythan the FES in detecting loss of
confi-dence in seniors who are otherwise high-ly functioning.21
Lachman, et al. developed the Surveyof Activities and Fear of
Falling in theElderly (SAFE), which examines 11 activ-ities of
daily living, instrumental activi-ties of daily living, mobility
tasks andsocial activities, using the questions list-ed in Table 1
for each activity.22 In con-trast to the FES, the SAFE does
notrequire subjects to make hypotheticalresponses about activities
that they donot actually perform.
Nadine Gagnon, MD, FRCP(C), Research Fellow, Department of
Psychiatry,University of Toronto and University Health Network, and
Toronto RehabilitationInstitute,Toronto, ON.
Alastair J. Flint, MB, ChB, FRCP(C), FRANZCP, Professor of
Psychiatry,University of Toronto, and Head, Geriatric Psychiatry
Program, University HealthNetwork,Toronto, ON.
Falls & Fitness
To date, researchers have addressed many aspects of
falling.During the past two decades, therehas been increasing
interest in the phenomenon of fear of falling.This paper
summarizesdata pertaining to the epidemiology, assessment and
management of fear of falling, as well asthe relationship of fear
of falling to other factors.
Key words: fear of falling, elderly, epidemiology,
self-efficacy, activities of daily living.
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16 GERIATRICS & AGING July/August 2003 Vol 6, Num 7
Fear of Falling
Associated Factors and ComorbiditiesOnly 1015% of falls result
in fracturesor soft tissue injuries severe enough tocause
immobilization or hospitaliza-tion.23 Thus, factors other than
physi-cal injury also play a role in thedevelopment of fear and
restriction ofactivities following single or repeatedfalls. To
date, studies that have exam-ined correlates of fear of falling
haveprimarily focused on demographic,physical and social variables.
Multiplevariables have been found to be asso-ciated with fear of
falling, includingthose listed in Table 2.3,4,6,13,15,18 Thus,like
falling itself, fear of falling is mul-tifactorial in origin.
A few studies have also employeddepression and anxiety
screeningscales.3,6,8,13,15,16 Most, but not all, ofthese studies
found more severe scoresof depression and/or anxiety amongpersons
with fear of falling comparedwith those who are not fearful. In
these
studies, depression and anxiety scoreswere highly correlated.
Dowton andAndrews found that, of eight variablesstudied, depression
and anxiety scoreswere the two most important predictorsof chronic
dizziness which, in turn, wassignificantly associated with fear
offalling.3 One study found that fallerswith a fear of falling were
significantlymore likely to score above 11 on theGeriatric
Depression Scale.6 This scoreis frequently used as a cut-off point
toindicate mild or more severe depres-sion, raising the possibility
that minoror major depressive disorders may bemore prevalent among
fearful than non-fearful fallers. However, to date therehas been no
attempt to actually deter-mine, by means of diagnostic inter-views,
whether depressive and anxietydisorders are more prevalent in
fearfulfallers. Furthermore, there has been noattempt to determine
whether specificpersonality traits or coping styles pre-dict fear
of falling.
ManagementDespite the high prevalence of fear offalling and its
associated morbidity,there has been little research into
itsmanagement.
Two fall prevention studies includedfalls efficacy or fear of
falling as a second-ary measure. Tinetti, et al. found that
amultiple risk factor intervention strategyresulted in a
significant reduction in riskof falling and a significant
improvementin FES scores among elderly people livingin the
community.24 On the other hand,Reinsch, et al. found that a
combination ofexercise, education and relaxation train-ing did not
have a significant effect on theprobability of falling or fear of
falling.25
Three randomized controlled trialshave examined the effect of
interventionson falls efficacy and/or fear of falling asthe primary
outcome variable. Tennstedt,et al. evaluated an intervention
specifi-cally designed to reduce fear of fallingand improve
self-efficacy in a populationof community-dwelling elderly
whoreported restriction in activity due to fearof falling.26 Their
cognitive-behaviouralintervention program had an immediate,but
modest, effect in improving subjectsself-efficacy and increasing
their level ofintended activity. However, these posi-tive effects
were not present at six monthfollow-up. Wolf, et al. found a
statistical-ly significant reduction in fear of falling,as well as
risk of falling, among elderlypeople randomized to 15 weeks of
TaiChi compared to those in the control con-dition.27 Finally,
Cameron, et al. foundthat the use of hip protectors in elderlywomen
who had fallen in the previousyear had no statistically significant
effecton fear of falling, but was associated withimproved
self-efficacy.28
On the basis of these studies, withtheir varied interventions
and disparateresults, it is difficult to derive recommen-dations
regarding the management offear of falling. The multifactorial
natureof fear of falling suggests that a multifac-eted approach
utilitizing both psycho-logical and physical interventions maystand
the best chance of success, but thisremains to be determined in
futureresearch. Furthermore, it is quite possible
1) Do you currently do the activity? (yes/no)
2) If you do the activity, when you do it how worried are you
that you might fall? (not at all, a little, somewhat, or very
worried)
3) If you do not do the activity, do you not do it because you
are worried that you might fall? (not at all, a little, somewhat,
or very worried)
4) If you do not do the activity because of worry, are there
also other reasons that you do not do it? (specify)
5) If you are not worried, what are the reasons you do not do
it? (specify)
6) Compared to five years ago, would you say that you do it
more, about the same or less than you used to?
Activities of Daily Living Assessed
Go to the store Visit a friend or relative
Prepare simple meals Reach for something over your head
Take a tub bath Go to a place with crowds
Get out of bed Walk several blocks outside
Take a walk for exercise Bend down to get something
Go out when it is slippery
Survey of Activities and Fear of Falling in the
Elderly(SAFE)
Table 1
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www.geriatricsandaging.ca 17
Fear of Falling
that the approach to managing fear offalling in non-fallers will
differ from theapproach needed for fallers.
Future DirectionsFurther research is needed in order to bet-ter
understand the genesis of fear offalling, improve its management
anddiminish its consequences. It would be ofinterest to clarify
variables that may pre-dict which individuals develop fear
offalling as an appropriate or protec-tive response to falls versus
those inwhom the fear is clearly pathological. Agreater research
focus on the psycholog-ical and psychiatric correlates of fear
offalling would be helpful in this regard.Furthermore, it will be
important todetermine whether interventions that
place greater emphasis on the specifictreatment of depression,
anxiety, negativecognitions and avoidant behaviours canresult in
improved outcome among olderpeople with fear of falling.
No competing financial interests declared.
References1. Marks I, Bebbington P. Space phobia: syn-
drome or agoraphobic variant? BMJ1976;2:345-7.
2. Murphy J, Isaacs B. The post-fallsyndrome: A study of 36
elderly patients.Gerontology 1982;28:265-70.
3. Dowton JH, Andrews K. Postural distur-bance and psychological
symptomsamongst elderly people living at home. IntJ Geriatr
Psychiatry 1990;5:93-8.
4. Maki BE, Holliday PJ, Topper AK. Fear offalling and postural
performance in theelderly. J Gerontol 1991;46:M123-31.
5. Lawrence RH, Tennstedt SL, Kasten LE, etal. Intensity and
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Aging Health 1998;10:267-86.
6. Arfken CL, Lach HW, Birge SJ, et al. Theprevalence and
correlates of fear of fallingin elderly persons living in the
communi-ty. Am J Public Health 1994;84:565-70.
7. Howland J, Lachman ME, Peterson EW, etal. Covariates of fear
of falling and associ-ated activity curtailment.
Gerontologist1998;38:549-55.
8. Tinetti ME, Richman D, Powell L. Fallsefficacy as a measure
of fear of falling. JGerontol 1990;45:P239-43.
9. Hill KD, Schwartz JA, Kalogeropoulos AJ,et al. Fear of
falling revisited. Arch PhysMed Rehabil 1996;77:1025-9.
10. Tinetti ME, Mendes de Leon CF, Doucette JT,et al. Fear of
falling and fall-related efficacy inrelationship to functioning
among communi-ty-living elders. J Gerontol 1994;49:M140-7.
11. Friedman SM, Munoz B, West SK, et al.Falls and fear of
falling: Which comesfirst? A longitudinal prediction model
sug-gests strategies for primary secondary pre-vention. J Am
Geriatr Soc 2002;50:1329-35.
12. Vellas BJ, Wayne SJ, Romero LJ, et al. Fearof falling and
restriction of mobility in eld-erly fallers. Age Ageing
1997;26:189-93.
13. Drozdick LW, Edelstein BA. Correlates offear of falling in
older adults who haveexperienced a fall. Journal of
ClinicalGeropsychology 2001;7:1-13.
14. Franzoni S, Rozzini R, Boffelli S, et al. Fearof falling in
nursing home patients. Geron-tology 1994;40:38-44.
15. Burker EJ, Wong H, Sloane PD, et al. Predic-tors of fear of
falling in dizzy and nondizzyelderly. Psychol Aging
1995;10:104-10.
16. Clague JE, Petrie PJ, Horan MA. Hypocap-nia and its relation
to fear of falling. ArchPhys Med Rehabil 2000;81:1485-8.
17. Cumming RG, Salked G, Thomas M, et al.Prospective study of
the impact of fear offalling on activities of daily living,
SF-36scores, and nursing home admission. JGerontol
2000;5:M299-305.
18. Howland J, Peterson EW, Levin WC, et al.Fear of falling
among the community-dwelling elderly. J Aging
Health1993;5:229-43.
19. Bandura A. Self-efficacy mechanism inhuman agency. Am
Psychol 1982;2:122-47.
20. Hellstrom K, Lindmark B. Fear of fallingin patients with
stroke: A reliability study.Clin Rehabil 1999;13:509-17.
21. Powell EL, Myers AM. The Activities-spe-cific Balance
Confidence (ABC) Scale. JGerontol 1995;50A:M28-34.
22. Lachman ME, Howland J, Tennstedt S, etal. Fear of falling
and activity restriction:the Survey of Activities and Fear of
Fallingin the Elderly (SAFE). J Gerontol1998;53B:P43-50.
23. King MB, Tinetti ME. Falls in community-dwelling older
persons. J Am Geriatr Soc1995;43:1146-54.
24. Tinetti ME, Baker DI, McAvay G, et al. Amultifactorial
intervention to reduce therisk of falling among elderly people
livingin the community. New Engl J Med1994;331:821-7.
25. Reinsch S, MacRae P, Lachenbruch PA, etal. Attempts to
prevent falls and injury: aprospective community study.
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26. Tennstedt S, Howland J, Lachman M, et al.A randomized
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improve falls self-effica-cy. Age Ageing 2000;29:57-62.
Older age
Being female
Experience of previous falls
Falls requiring medical attention
Falls resulting in fracture
Falls that occur in circumstances other than a slip or trip
Delay getting up after a fall
Recency of a fall
Decreased mobility
Poor performance on tests of balance
Chronic dizziness
Higher levels of pain
Living alone or having fewer social contacts
Poor life satisfaction
Factors suggesting frailty in the elderly,such as needing
assistance to climb stairs,poor vision limiting walking, use of
anassistive ambulatory device, restriction ininstrumental
activities of daily living andpoor self-rated health
Factors Associated withFear of Falling
Table 2
