Fear of falling and activity avoidance in a national sample of older adults in the United States.
Much work has focused on investigating factors associated with the etiology of falls (Dos & Joseph, 2005; Rigler, 1999). However, less attention has been paid to social and behavioral correlates of falls (Lach, 2005; Li, Fisher, Harmer, & McAuley, 2005; Parker, 2000), including the predisposing factors and consequences of falls.
In a prospective study in 20 independent-living facilities in Atlanta, activity-related fear of falling was higher in African American older adults than it was in Caucasian older adults (Kressig et al., 2001); depression, slow gait, and the use of a walking aid were independently related to fear of falling. Among a representative sample of community-dwelling older adults age 72 years or older, women were about twice as likely as men to experience a fall with serious injury (Tinetti, Doucette, & Claus, 1995). Another study showed that older age and black race were negatively associated with the ability to walk at least eight blocks per week (Simonsick, Guralnik, & Fried, 1999).
Fear of falling has been linked with physical health status and psychological factors. Fear of falling has been associated with lower activities of daily living (ADL) scores; for example, fear of falling was mainly predicted by lower ADL scores and the presence of depression in a study of older adults with chronic dizziness (Burker et al., 1995). In a more recent study of 7,364 women over 75 years of age, fear of falling, but not falls, was significantly associated with having a disability around at least one ADL (Nourhashemi et al., 2001). Consistent with this research, fear of falling has also been independently associated with poor health status in a longitudinal study of 890 community-dwelling older adults (Lach, 2005). Among community-dwelling older women, reductions in mobility accounted for fear of falling more than did psychological factors (Martin et al., 2005). In summary, there is a growing body of evidence that suggests that fear of falling may constitute an important risk factor for unnecessary restriction of activity that can lead to greater disability and ultimately reduced ability to live independently.
Fear of falling has been associated with activity limitation in a few recent studies. In a study of 713 community-dwelling young-old women, for example, fear of falling was related to early reduction of mobility function, suggesting that it may help to identify individuals at risk of subsequent functional decline (Martin et al., 2005). A study of older adults with a fear of falling had marked deficits in strength (lower limb weakness) and slower walking speed, despite living independently in the community and being in good general health, compared with those without fear, which underscores the seriousness of fear of falling as a potential health risk factor in the well elderly population (Brouwer, Musselman, & Culham, 2004).
The beliefs and behaviors of those who fear falling may be understood and examined in the context of threat avoidance logic. The Health Belief Model incorporates this approach by accounting for the perceived susceptibility and seriousness of a threat, perceived benefits of various actions to reduce a threat, and self-efficacy related to one's ability to take actions that will reduce a perceived threat (Rosenstock, 1990). In the case of falls in older adults, fear of falling is an indication of perceived susceptibility, and the seriousness of the perceived threat is measured by the chances that a future fall will reduce independence and quality of life. In this scenario, a reasonable behavioral response to the threat of falling would be avoiding activities that might lead to a future fall. Higher fear levels would be expected to be associated with greater activity avoidance behavior. This is due to the tendency that when fear arousal levels are too high they lose their potential for positive adaptation, create a defensive response, and increase the likelihood of inaction or avoidance of the activity that is perceived to cause the threat.
This study explores the relationship between fear of falling and avoidance of nine everyday activities critical to maintaining independence among a national sample of community-dwelling older individuals. Through the use of the literature on falls and the Health Belief Model framework, the following research hypotheses were formulated:
1 Hypothesis 1: Those who have the greatest fear of falling among older adults will have characteristics that reflect vulnerability in terms of social, demographic, and health status. These characteristics include older age, minority group membership, lower income, lower education, living alone, needing help with ADL, and taking more prescription medications.
Hypothesis 2: Fear of falling will be the most important factor related to avoidance of activity in older adults. This relationship will hold after controlling for ADL status, number of prescription medications, and social and demographic characteristics, all of which may be related to activity avoidance.
Hypothesis 3: Fear of falling will be more strongly associated with activity avoidance among older adults who have fallen in the past year compared with those who have not fallen.
The present study used secondary data analysis of survey results collected during the National Survey of Self-Care and Aging (DeFriese & Kincade Norburn, 1992).The population for this study was interviewed from a random sampling of community-dwelling Medicare beneficiaries 65 years of age or older (Kincade et al., 1996). The original data set contained responses from 3,485 Medicare beneficiaries 65 years of age or older. Preliminary analysis showed that 11 of these respondents provided incomplete data for the variables of interest for the present study, so their responses were not included, resulting in a study population of 3,474.
Approximately half (52.6 percent) of the study population (N = 3,474) was female, and about two-thirds was 75 years of age or older. The vast majority was white (91.0 percent), with the remainder being black (4.75 percent), Hispanic (3.4 percent), or other (.9 percent). The majority was currently married (56.1 percent), had completed high school (58.4 percent), and had an annual income of less than $20,000 (64.9 percent).
The data for this study consists of responses to an interviewer-administered questionnaire. Falls were measured by the question, "Did you experience a fall in the past year?" The frequency of falling was measured by the question, "How often did you experience a fall in the past year?" Response categories were zero, one, two, three, or four or more times. Fear of falling was measured by the question, "Did you fear falling in the past year?" Response categories were everyday, once/twice per week, once/twice per month, a few times, or never. Health status indicators such as ADL status and prescription drug use were also included in the study as independent variables. Those who reported needing help with at least one ADL during the past 12 months were coded as needing help. The actual number of prescription drugs used in the past four days were added and used as the measure of prescription drug use.
Avoidance of activities was used as a dependent variable and measured by nine items: (1) "Do you do things less often or more slowly?" (2) "Do you avoid lifting heavy objects?" (3) "... bending or stooping?" (4) "... walking?" (5) "... using stairs?" (6) "... reaching overhead?" (7) "... going outside?" (8) "... gripping and opening things?" and (9) "... medications that make you dizzy?" These items were added together and used in a scale after factor analysis with varimax rotation demonstrated that they all loaded high (.55 to .78) on the primary factor; the three items that loaded on the second factor or on neither were dropped from the scale ("take the bus," "do other things," or "use the phone more"). Reliability analysis indicated that the nine items had an acceptable degree of internal consistency (Cronbach's [alpha] = .83).
Descriptive statistics and cross-tabulations of demographic variables and fear of falling were used to test hypothesis 1. A linear regression model was developed to investigate relationships among the variables of interest. The independent variables were fear of falling in the past year, needing help with one or more ADL in the past year, and the number of prescription drugs taken in the past four days. Sociodemographic factors such as age, gender, household income, years of education, and marital status were added to the model to control for possible confounding factors identified in the earlier analysis. The dependent variable was the score on the index of activities that had been avoided in the past year. A hierarchical model was used to test hypotheses 2 and 3. To test hypothesis 2, all independent and control variables were entered into the model. On the second step, all variables on the first step were entered along with the variable measuring whether the individual experienced a fall during the past year. The interaction of fear of falling and number of falls was tested and plotted to show the direction of the interaction. SPSS Version 12.1 (SPSS, 2003) was used to conduct the analysis.
Preliminary analysis of the study population (N = 3,474) showed that 24 percent of respondents 65 years of age or older experienced a fall in the past year, and 39 percent experienced fear of falling at least a few times in the past year. More than two-thirds reported that they avoided at least some activities, such as going outside, walking, reaching, gripping, lifting, bending, or stooping.
The first hypothesis is that those who have the greatest fear of falling among older adults will have characteristics that reflect vulnerability in terms of social and demographic characteristics. The oldest (85 years or older) respondents were four times as likely to report experiencing a fear of falling everyday compared with the youngest respondents (65 to 74 years old), and the fear of falling increased with age, as is shown in Table 1 .Women were more likely to fear falling everyday compared with men, as were those who lived alone, had less than a high school education, and had lower household income (all ps < .001) (Table 1). Older adults who needed help with one or more ADLs were nearly five times as likely to experience fear of falling everyday compared with those who did not need help (p < .001). The only characteristic that did not have the hypothesized association with fear of falling was racial-ethnic group; no group had significantly higher reported fear of falls compared with the other groups. These results support hypothesis 1 and suggest that older adults who experience frequent fears of falling have social, demographic, and health characteristics that reflect greater vulnerability as measured by older age, lower income, lower education, living alone, and needing help with ADLs.
Hypothesis 2 examined more complex relationships among the variables: It was predicted that fear of falling would be the most important factor related to avoidance of activity in older adults. The results for the first step of the regression analysis are shown in Table 2 (left column). Fear of falling in the past year was positively associated with avoiding common activities such as lifting, bending, walking, reaching, and going outside ([beta] = .37, p < .001). Needing help with one or more ADLs and the number of prescription medications taken were also positively associated with activity avoidance ([beta]s = .23 and .12, respectively; both ps < .001). Of the social and demographic variables, female gender and older age showed a modest positive association with activity avoidance, whereas lower income was inversely associated with activity avoidance (-.09). Education and living alone were not associated with activity avoidance in the model. The variables in step 1 of the model explain 35 percent of the variance in activity avoidance in the past year.
Hypothesis 3 predicted that fear of falling would be more strongly associated with activity avoidance among older adults who experienced a fall in the past year compared with those who did not fall. When history of falls in the past year was added to the model as the second step in the regression, the same associations emerged as did those in step 1. As predicted, experiencing at least one fall in the past year was positively associated with activity avoidance ([beta] = .13, p < .001). The addition of fall history increased the predictive value of the model to 36 percent of the variance in activity avoidance. Taken together, results from the two steps of the model support hypothesis 3, indicating that the model is better at predicting activity avoidance among older adults who experienced a fall in the past year compared with that among those who did not fall. The fact that the association between fear of falling and activity avoidance was slightly lower in step 2 suggests an interaction between fear of falling and fall history. The strength and direction of the interaction effect was tested and graphed. There was a significant interaction between fear of falling and fall history, F(19, 1976) = 53.8, p < .001. The number of falls an individual experienced in the past year influenced the strength of the relationship between fear of falling and activity avoidance (Figure 1). There was a stepwise interaction between the number of falls and fear of falling such that activity avoidance was lowest for individuals with no falls at each level of fear. Activity avoidance increased as the number of falls and frequency of fear of falling increased.
Respondents who experienced a fall in the past year were significantly more likely to avoid each of nine activities (see Table 3). The most frequently avoided activities were, in rank order, doing things less often or more slowly (74.2 percent), avoiding lifting (67.1 percent), and avoiding bending or stooping (40.5 percent). The other activities that were limited by respondents included walking, using stairs, reaching overhead, and going outside, each of which was reported by at least 25 percent of those who experienced a fall. These results suggest that people 65 and older who experienced a fall exhibited significant avoidance behaviors that could in themselves affect health and quality of life by increasing social isolation, increasing dependence, and decreasing physical fitness.
In a large, national sample of adults 65 years of age or older, fear of falling at least once or twice in the previous month was reported by 22 percent of respondents; and fear of falling increased with age was higher for women, those with lower income and education, and those who lived alone.
The association between fear of falling and activity avoidance was influenced by fall frequency in the past year. However, even those who had not experienced any falls showed significant activity avoidance as the frequency of fear of falling increased (Figure 1).This finding underlines the importance of the psychological component in understanding the consequences associated with falls and fall-related behavior. The fact that the association between fear of falling and activity avoidance was significant even for individuals who did not fall suggests that some significant portion of the fear of falling may not be appropriate and may not reflect an accurate assessment of the individual's physical and mental condition.
Other factors that consistently increased the risk of activity avoidance were needing help with ADLs, the number of prescription medications taken, and lower income. This is consistent with other research that showed marked deficits in strength and health status among older adults living independently in the community, who are in good health but report being fearful of falling (Brouwer et al., 2004). This is consistent with a view that fear of falling is an independent factor (Li, Fisher, Harmer, McAuley, & Wilson, 2003) and that fear of falling is a potential cause of excess disability as it causes some older adults to unnecessarily restrict physical activity (Lach, 2005), regardless of fall status.
[FIGURE 1 OMITTED]
Implications for Practice
A national survey conducted by the Center for Health Workforce Studies (2006) for NASW estimated that at least 220,000 licensed social workers serve older adults in the United States. The most common practice areas for these social workers are mental health, medical, or aging. On the basis of the prevalence of falls and fear of falling from the present study, up to half of social workers who serve older adults will come into contact with someone who has experienced a fall, who fears falling, or both. The results of this study suggest that fear of falling should be given more consideration in social work assessments and intervention plans and in designing future research that involves community-dwelling older adults. The need for assessment is especially critical for those with predisposing factors, such as needing help with ADLs, taking several prescription medications, or low income. Making such assessments more widespread requires research on practical assessment tools and checklists to assess risk of falling and fear of falling because at present no one test alone is able to identify an individual who may be at higher risk and a candidate for an intervention program (Hotchkiss et al., 2004). This underlines the need for development of better assessment tools that are practical for use in measuring the risks and consequences of falls in older adults.
During an assessment of a person's mental and physical health, it is important that social workers recognize that a fear of falling may start simply as an unpleasant feeling in the aftermath of a fall, a near fall, or a dizziness episode. At this stage, individuals may fear that the next incident may cause either psychological or physical damage, such as embarrassment, injury, or loss of independence. Asking older adults to explain the frequency and circumstances of their fear is the next step in a fall assessment. However, some older adults with cognitive impairment may not be able to adequately express their fear of falling, which suggests that relatives and friends should be included when conducting an initial assessment to gather information. An alternative assessment approach would be to ask, "Have you recently avoided any activities?" Inquiring about whether a person has restricted activities in response to a recent fall, near fall, or dizziness may yield a better indication of a clinically significant fear of falling than directly asking individuals if they are fearful of falling (Tideiksaar, 1997). Another indirect approach to understanding fear is to probe self-efficacy related to everyday activities (Li et al., 2005), which may be easier for some individuals to talk about. Another technique is to observe the individual at home while they attempt daily activities, to identify fears that may not be verbalized but that can be signaled by body language that reflects avoidance behavior. In conjunction with a determination of the presence and intensity of fear of falling, the assessment should include an older person's physical status, gait, and balance, regardless of whether he or she has experienced a fall.
A social work assessment may already include various psychosocial conditions that the older person may experience as a predisposing factor or as a consequence of a fall or near fall. These conditions may include depression, feelings of anxiety about the management of their daily activities, feelings of frailty, loss of control, and increased dependence, all of which are important to older people who want to "age in place." Despite a responsive support system, many active people may find it difficult to accept becoming "dependent" on others. Some may fear placing a greater burden of care on their spouses or children. Thus, it is essential to involve the family or significant others in the assessment and management of fear of falling.
Once the fear of falling is assessed, interventions that help to reduce it while returning older adults to higher levels of independence and functioning could include rehabilitative training and social support to gain confidence in how to fall and get up, environmental changes such as acquiring and using appropriate assistive devices, and psychosocial support that enables older adults to recognize that fear of falling may influence quality of life by unnecessarily restricting everyday activities that may be key to retaining independence. Studies have reported beneficial effects associated with physical activity interventions designed to alter the frequency or severity of falls (Campbell et al., 1997). Interventions designed to increase physical activity may be strengthened by including fear of falling assessment and reduction. Among the interventions that show promise to reduce fear of falling is Tai Chi training (Sattin, Easley, Wolf, Chen, & Kutner, 2005).
Our results are consistent with the Health Belief Model that predicted that avoidance of activity would be highest among older adults who had the strongest fear of falling. The strength of this association was significant even if an individual had not experienced a fall, suggesting that the psychological process of fearing a fall was not dependent on the personal experience of an actual fall. Future research with this model should examine the precursor variables that might explain how the perceived threat of a fall is formed: How much of the fear of falling is influenced by the fall experiences of others, by fall near misses, or by symptoms such as unsteadiness or dizziness.
The study used secondary analyses of a national interview survey that is cross-sectional rather than prospective. This limits the ability to demonstrate causality in relationships among variables, which could have benefited from a prospective design that followed the older adults over time. Data were limited to events during the past year, which in turn limited our ability to examine whether fear of falling was present before or after a fall and whether the most recent fall was the first or a recurrence of a pattern of falls that started prior to the study year. Because of these factors, the causal ordering of variables in the models should be interpreted with caution.
These limitations notwithstanding, the consistency, direction, and strength of the associations found, as well as the national sample used, make it unlikely that these limitations would change the conclusions of the study. Our findings may be useful in highlighting key aspects of falls that have not received sufficient attention in the literature or in practice, especially in relation to social work assessment of older adults. Future fall research and intervention efforts should incorporate a multidisciplinary approach that addresses psychosocial, environmental, and rehabilitative approaches (Murphy, Dubin, & Gill, 2003), along with assessments of older community-dwelling individuals that include fear of falling. The successful implementation of this approach could help to address one of the most important predictors of activity avoidance and could provide significant individual and societal benefits by helping to maintain optimal functioning and independent living among older adults.
Original manuscript received October 18, 2006
Final revision received April 10, 2007
Accepted August 9, 2007
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Elizabeth M. Bertera, PhD, is associate professor, School of Social Work, Howard University, 60I Howard Place, NW,, Washington, DC 20059; e-mail: email@example.com. Robert L. Bertera, DrPH, is adjunct associate professor, School of Public Health, George Washington University, Washington, DC. This study was funded in part by a grant from the Erickson Foundation, Baltimore.
Table 1: Percentage Distribution of Fear of Falling Frequency in the Past Year, by Demographic and Health Variables Fear of Falling Frequency Few 1-2 Times/ 1-2 Times/- Variable Never Times Month Week Age 65-74 71.1 16.1 3.5 3.4 75-84 62.6 17.1 3.6 3.9 [greater than or 43.6 19.3 6.1 6.5 equal to] 85 Total 60.6 17.3 4.2 4.4 Gender Female 51.9 20.6 5.4 5.4 Male 68.4 14.4 3.2 3.5 Race-ethnicity White 61.0 16.8 4.2 4.4 African American 53.8 24.7 4.4 5.1 Hispanic 54.0 21.2 4.4 5.3 American Indian, Asian, 71.0 19.4 3.2 0.0 or other Lives alone No 63.2 16.6 4.0 4.2 Yes 53.1 19.5 4.9 5.2 Years of education <High school 53.6 18.3 4.6 5.6 [greater than or equal 65.3 16.7 3.9 3.7 to] High school Annual income $0-$9,999 47.3 19.5 6.0 6.6 $10,000-$19,999 61.5 18.5 3.4 4.4 [greater than or 70.4 13.9 3.2 3.9 equal to] $20,000 Activities of daily living Does not need help 72.5 16.6 3.1 2.5 Needs help with one 44.6 18.3 5.7 6.9 or more Fear of Falling Frequency Variable Everyday [chi square] Age 65-74 6.0 236(8, N= 3,424) *** 75-84 12.9 [greater than or 24.5 equal to] 85 Total 13.5 Gender Female 16.7 98(4, N= 3,424) *** Male 10.5 Race-ethnicity White 13.6 1302, N= 3,421) African American 12.0 Hispanic 15.0 American Indian, Asian, 6.5 or other Lives alone No 12.0 32(4, N= 3,155) *** Yes 17.3 Years of education <High school 18.0 62(4, N=3,394) *** [greater than or equal 10.4 to] High school Annual income $0-$9,999 20.6 117(8, N= 2,695) *** $10,000-$19,999 12.2 [greater than or 8.5 equal to] $20,000 Activities of daily living Does not need help 5.2 389(4, N= 3,424) *** Needs help with one 24.5 or more *** p < .001 Table 2: Regression of Avoiding Activities Score (Dependent Variable), by Fear of Falling in the Past Year, ADL Help Status, Prescription Medications Taken, Social and Demographic Characteristics (Step 1), and Fall Status in the Past Year (Step 2) Step 1 Variable [beta] t Feared falling 1n past year .37 19.5 *** Needed help with one or more ADL .23 13.1 *** Number of prescription medications .12 6.9 *** taken in the past four days Female .06 3.3 ** Age [greater than or equal to] 75 .05 2.7 * Household income [greater -09 -4.6 *** than or equal to] $20,000 [greater than or equal to] -.03) -1.3 High school education Lives alone .03 1.7 Fell at least once in past year .13 7.2 *** [R.sup.2] .346 Number 2,155 Step 2 Variable [beta] t Feared falling 1n past year 17.0 *** Needed help with one or more ADL .23 12.4 *** Number of prescription medications .12 6.6 *** taken in the past four days Female .05 3.2 ** Age [greater than or equal to] 75 .04 2.3 * Household income [greater -08 -4.4 *** than or equal to] $20,000 [greater than or equal to] -.03 -1.3 High school education Lives alone .03 1.4 Fell at least once in past year [R.sup.2] .361 Number 2,155 Note: ADL = activities of daily living. * p < 05, ** p < .01, *** p < .001. Table 3: Percentage Avoiding Activities, by Fall Status, N = 3.474 Fell in Past Year Activity No Yes [chi square] (1) Do things less often or more slowly 45.1 74.2 241 *** Avoid liking heavy object 43.3 67.1 143 *** Avoid bending or stooping 15.7 40.5 230 *** Avoid walking 15.5 38.5 202 *** Avoid using stairs 13.9 34.8 181 *** Avoid reaching overhead 12.8 31.3 152 *** Avoid gripping and opening things 10.7 29.4 173 *** Avoid going outside 8.1 26.2 191 *** Avoid medications that make me dizzy 12.3 22.4 50 *** *** p < .001.
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|Author:||Bertera, Elizabeth M.; Bertera, Robert L.|
|Publication:||Health and Social Work|
|Date:||Feb 1, 2008|
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