Why should clinical practitioners ask about their patients' concerns about falling?

Item Response Theory of the English Version of the Falls Efficacy Scale-International Tool Among Community-Dwelling Older Adults From Four Different Sites

BACKGROUND AND PURPOSE

The Falls Efficacy Scale-International (FES-I) is widely used in clinical practice, but it is unclear how each item can discriminate different levels of fall concern. This study applied item response theory (IRT) to evaluate the psychometric properties of each item in the original English version of FES-I among older adults, and compared those properties across genders and with translations in French, Portuguese, and Spanish.

METHODS

This cross-sectional study used data from the International Mobility in Aging Study, which recruited community-dwelling older adults. Modified graded IRT was used to assess the psychometric properties of the FES-I items, specifically estimating difficulty and discrimination (ie, ability to differentiate levels of fall concern) parameters. Item reliability across the different levels of fall concern was estimated and differential item functioning (DIF) was tested for each item to assess if participants perceived the items similarly regardless of gender and language.

RESULTS AND DISCUSSION

The study included 1608 community-dwelling older adults, of which 395 had completed the English version of the FES-I. Generally, the IRT results showed that the English version was a reliable tool, especially for older adults with high fall concerns, but did not distinguish between low and moderate levels of concern. Factor analysis supported the construct validity of the FES-I. In the DIF analysis, 2 items were perceived differently by gender in the English version, and 9 items were perceived differently between the English and the translated versions (French, Spanish, and Portuguese). The presence of DIF indicates that the psychometric properties of these items are different across genders and languages, and they might relate to cultural factors, the surrounding environment, the wording, the biological differences between men and women, and the item's task itself.

CONCLUSIONS

The FES-I is a reliable and valid scale for identifying older adults with high fall concern, but it should include more difficult items. Additionally, differing perceptions of items across genders and languages necessitate caution in comparing results among diverse populations.

Development, reliability, and validity assessment of a fall concerns scale for people who use wheelchairs and scooters (FCS-WC/S)

PURPOSE

To evaluate the psychometric properties of a Fall Concerns Scale for people who use Wheelchairs and Scooters (FCS-WC/S).

MATERIALS AND METHODS

Developed by fall prevention experts, FCS-WC/S underwent refinement through interdisciplinary reviews and focus groups with researchers, clinicians, and individuals who use WC/S full-time. The psychometric evaluation involved adults who used WC/S for ≥1 year and had ≥1 fall in the previous 3 years, recruited between April and September 2022.

RESULTS

The FCS-WC/S evaluates fall concerns among people with various health conditions who use WC/S full-time across 33 daily activities. One hundred and twenty-four participants responded to the baseline survey. A subgroup of 63 people repeated the FCS-WC/S a week later. The FCS-WC/S demonstrated excellent internal and good test-retest reliability (α ≥ 0.90, ICC = 0.86-0.9), as well as concurrent validity (Spearman's rho = 0.72) with the Spinal Cord Injury Falls Concern Scale (SCI-FCS). It effectively differentiated fear of falling levels from an established measure (ORs 4.1, 25.8, 46.7). Factor and parallel analysis revealed three factors, two of which were retained for further analysis.

CONCLUSIONS

Preliminary findings support FCS-WC/S validity and reliability for assessing fall concerns among individuals with various conditions who use WC/S. Further scale construction analysis is recommended.

Factors influencing fall prevention programmes across three regions of the UK: the challenge of implementing and spreading the Falls Management Exercise (FaME) programme in a complex landscape

BACKGROUND

The occurrence of falls in adults 65+ years remains a common and costly issue worldwide. There is current evidence to suggest that falls can be prevented using evidence-based strength and balance interventions, such as the six-month Falls Management Exercise (FaME) programme. Perspectives of multiple key partners and providers of the FaME programme could inform future implementation and fall prevention strategies.

METHODS

Partners and providers involved in local community fall prevention pathways were purposefully recruited from three geographical areas across the UK. Semistructured interviews were conducted to gain a broad understanding of factors affecting the adoption, implementation and spread of FaME. Data were analysed using an inductive thematic approach and mapped to the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Data from 25 participant interviews and document analysis revealed 11 themes organised within five CFIR domains-the innovation (3), outer setting (3), inner setting (1), characteristics of individuals (1) and process (2).

CONCLUSION

The adoption, implementation and spread of FaME into community settings is complex and faces multiple health system challenges. For adoption and implementation to be facilitated, FaME programmes must demonstrate effectiveness and fit the local needs of those receiving the intervention. For spread to occur, influential decision-makers and funders must support wider programme rollout whilst also securing sufficient expert capacity to deliver the programme and ensure monitoring is in place to determine effectiveness of provision for older adults.

Does concern about falling predict future falls in older adults? A systematic review and meta-analysis

BACKGROUND

The 2022 World Falls Guidelines recommend assessing concerns (or 'fears') about falling in multifactorial fall risk assessments. However, the evidence base for this recommendation is limited. This review evaluated the evidence for concerns about falling as an independent predictor of future falls, applying the Bradford Hill criteria for causality.

METHODS

Systematic review and meta-analyses were conducted (PROSPERO registration ID: CRD42023387212). MEDLINE, CINAHL Plus, Web of Science and PsycINFO were searched for studies examining associations between baseline concerns about falling and future falls in older adults (minimum 6-month follow-up). Meta-analyses examined associations between concerns about falling and future falls. Risk of bias was assessed using an adapted Newcastle Ottawa Scale for cohort studies, and evidence certainty was rated with GRADE.

RESULTS

About 53 studies, comprising 75,076 participants, were included. Meta-analysis showed significant independent association between baseline concerns and future falls when using the Falls Efficacy Scale-International to assess concerns (full scale version, pooled OR = 1.03 [95% CI = 1.02-1.05] per 1-point increase; short scale version, pooled OR = 1.08 [95% CI = 1.05-1.11]). Significant associations were also observed when using single-item measures of concerns (pooled OR = 1.60 [95% CI = 1.36-1.89] for high vs. low concerns). In contrast, balance confidence (Activities-Specific Balance Confidence Scale) did not predict future falls (pooled OR = 0.97 [95% CI = 0.93-1.01]). Despite 26 studies rated as poor quality, associations were consistent across studies of different quality. The overall certainty of the evidence was rated as moderate.

CONCLUSIONS

Baseline concern about falling is a clear predictor of future falls in older adults, supporting its inclusion in fall risk assessments. Regular assessment of concerns about falling, along with targeted interventions, could help reduce the risk of falls in older adults.

Predictive factors of concern about falling after hospital discharge among older adults with fragility hip fractures: a prospective cohort study

PURPOSE

Concern about falling [CaF] is common among older adults, particularly after fragility hip fracture. This condition is associated with adverse health outcomes and a reduced quality of life. The aim of this study is to explore predictors of CaF among older patients with fragility hip fractures 2 weeks after hospital discharge.

METHODS

A prospective observational cohort study was conducted at a Tertiary Care Hospital in Thailand. Participants were patients aged 60 years and above who had fragility hip fractures and were admitted to the hospital from March 2023 to March 2024. CaF was assessed using the short Falls Efficacy Scale-International 2 weeks after hospital discharge. Predictors examined pre-fall characteristics, fall-related data, surgery-related data, and postoperative data. In the full model approach, the multivariable Gaussian regression was employed to identify predictive factors.

RESULTS

Of the 165 patients included in the study (mean age 78.76 ± 8.72 years), 79.39% were female. In the full model approach, pre-fracture activities of daily living (ADL) < 20 (adjusted mean difference [aMD] 3.44, 95% CI 1.04-5.85, p = 0.005) and shorter in-hospital duration of walking training (aMD - 0.66, 95% CI - 1.10 to - 0.22, p = 0.004) were identified as predictors of CaF at 2 weeks after hospital discharge.

CONCLUSIONS

The findings of this study emphasize the importance of assessing pre-fracture functional status and the shorter duration of in-hospital walking training as key predictors of CaF in older adults with fragility hip fractures. Enhancing functional capacity and extending the duration of walking training during hospitalization are crucial steps in reducing CaF in this population.

Fall risk perception in older adults: A concept analysis

BACKGROUND

Fall prevention is crucial for older adults. Enhanced fall risk perception can encourage older adults to participate in fall prevention programs. However, there is still no unified definition of the concept of fall risk perception.

OBJECTIVE

To explore the concept of fall risk perception in older adults.

DESIGN

A concept analysis.

DATA SOURCES

The literature was searched using online databases including PubMed, Cochrane Library, Embase, CINAHL Complete, PsycINFO, Web of Science, China National Knowledge Infrastructure, WangFang and SinoMed. Searches were also conducted in Chinese and English dictionaries. The literature dates from the establishment of the database to April 2023.

METHODS

The methods of Walker and Avant were used to identify antecedents, attributes and consequences of the concept of "fall risk perception" in older adults.

RESULTS

Eighteen publications were included eventually. The attributes were identified as: (1) dynamic change, with features of continuum and stage; (2) whether falls are taken seriously; (3) a self-assessment of the fall probability, which is driven by individual independence; and (4) involves multiple complex emotional responses. The antecedents were identified as: (1) demographic and disease factors; (2) psychological factors and (3) environmental factors. The consequences were identified as: (1) risk-taking behaviour; (2) risk compensation behaviour; (3) risk transfer behaviour; and (4) emotions.

CONCLUSION

A theoretical definition of fall risk perception was identified. A conceptual model was developed to demonstrate the theoretical relationships between antecedents, attributes and consequences. This is helpful for the development of relevant theories and the formulation of fall prevention measures based on fall risk perception as the intervention target.

Falls and physical function in older patients with Benign Paroxysmal Positional Vertigo (BPPV): findings from a placebo controlled, double blinded randomized control trial (RCT) investigating efficacy of vitamin D treatment in lowering the recurrence rate of BPPV

BACKGROUND

Benign Paroxysmal Positional Vertigo (BPPV) is the commonest cause of vertigo in older adults. Due to its high incidence in older adults presenting with falls, vestibular assessment is recommended in the World Guidelines for Falls Prevention. There is a paucity of evidence in well conducted randomised controlled trials (RCTs) to evaluate vitamin D for prevention of BPPV recurrence in relation to falls and function.

AIMS

Primary outcome: does vitamin D supplementation and dietary interventions in combination with standard care impact falls, fear of falling and function in patients with BPPV.

METHODS

Post hoc analyses of phase IIa single centre, placebo controlled, double blind RCT evaluating vitamin D supplementation with diet and Canalith Repositioning Procedure (CRP) [Group A] versus diet alone with CRP [Group B] in reducing BPPV recurrence rates and the consequent effects on falls and function.

RESULTS

53 participants were recruited. 14 were vitamin D replete at baseline (Group C) with remaining 39 randomised into Groups A and B. Group A had better 5x sit to stand time and 0.75 fewer clinical BPPV recurrences per one person year (P = 0.035) compared to Group B. 25% of participants who fell reported fear of falling compared to 43% in those without falls in the 12 month follow up.

DISCUSSION

Vitamin D supplementation alongside standard BPPV improved 5xchair stand test and reduced BPPV recurrence. Participants without an incident fall during follow up experience fear of falling, prompting further consideration.

CONCLUSION

Vitamin D replacement was associated with fewer BPPV recurrences and improved function assessed with 5x chair stand test.

Exploring how falls prevention practitioners assess and manage concerns about falling

BACKGROUND

Concerns about falling (CaF) are common in older adults. They can lead to various negative outcomes, including an increased risk for future falls. The Worlds Falls Guidelines recently published recommendations for assessing and treating CaF. However, the extent to which these guidelines have been adopted into falls prevention practice (in addition to the barriers preventing implementation) are currently unknown.

METHODS

A cross-sectional survey was completed by 114 healthcare professionals working in falls prevention and rehabilitation services in the UK and Ireland. The survey explored their experiences and perceptions regarding the management and assessment of CaF.

RESULTS

Only 39% of respondents reported using the Falls Efficacy Scale-International (FES-I), a tool recommended by the World Falls Guidelines for assessing CaF. Healthcare professionals in hospital settings were significantly less likely to use the FES-I compared to those working in the community (X2 = 6.324, p = 0.043). While there was no significant difference between settings regarding the type of intervention used to manage CaF, only about 50% of participants adopted a holistic approach combining physical and psychological strategies as recommended by the World Falls Guidelines. The most commonly identified barriers to clinical management of CaF were a lack of both time and perceived effective interventions, particularly for those working within hospital settings (X2 = 6.209, p = 0.013 and X2 = 3.752, p = 0.053, respectively).

CONCLUSION

These findings indicate low levels of adoption of the World Falls Guidelines recommendations for assessing and managing CaF, especially in hospital settings. Future work should focus on addressing these barriers to maximise the clinical adoption of these recommendations.

Is frailty associated with increased concerns about falling and activity restriction in community-dwelling older adults? A systematic review

PURPOSE

Concerns about falling (CaF) are common in older adults. They are associated with increased risk of falls, activity restriction, social isolation, and physical deconditioning. This systematic review assessed if frailty is a risk factor for CaF.

METHODS

Searches of cross-sectional and prospective studies exploring associations between frailty and CaF were conducted across five databases (Medline, CINAHL, Embase, Psychinfo and Scopus). The Risk of Bias in Non-randomised Studies of Exposure (ROBINS-E) was used to determine risk of bias.

RESULTS

The search identified 2492 articles, 12 were included for data extraction: 8 cross-sectional and 4 prospective studies. Participants' mean ages across the different studies ranged from 67.5 - 81.7 years. All adjusted analyses reported a significant association between increasing frailty and CaF, except for one cross-sectional paper. Significant adjusted Odd Ratios (ORs) ranged from 1.79 (CI = 1.18-2.71) to 144.78 (CI = 13.86 - 1512.60) for cross-sectional studies, and from 1.33 (CI = 1.04-1.69) to 12.4 (CI = 7.6-20.1) for prospective studies. Three studies (one cross-sectional and two prospective) explored the association between frailty and concern-related activity restriction: A significant association was reported in two prospective studies (adjusted OR = 1.58 (CI=1.09-2.30) and adjusted RRR = 3.91 (2.61-5.85)), but not the cross-sectional study (adjusted OR = 1.31 (CI=0.62-2.78)).

CONCLUSION

This review identifies strong associations between increasing frailty and both CaF and associated activity restriction. This expands previous work describing the opposite association (that CaF can lead to frailty), suggesting a bi-directional relationship. Clinicians working with pre-frail and frail older adults should consider screening for CaF.

PROSPERO

CRD42023371899.

Uncovering the boundary conditions of the association between concerns about falling and physical activity in adult populations: a scoping review protocol

INTRODUCTION

Despite evidence of variation in how concerns about falling influence physical activity, many of the currently available knowledge syntheses merely assume that this relation is uniform across populations and contexts. Therefore, we propose a scoping review protocol to guide a summary of the bodywork that has examined the association between concerns about falling and physical activity in adult populations, with an eye on the availability of empirical evidence of moderation.

METHODS AND ANALYSES

Studies reporting on both the concepts of concerns about falling and physical activity among samples with a mean age≥18 years will be included. Five electronic databases will be searched. We will conduct a hand search of the reference lists for all included studies and relevant knowledge syntheses and perform a citing reference search for all included studies using the Web of Science. A team of six reviewers will single-screen titles and abstracts. Two reviewers will independently assess the eligibility of each study based on a full-text examination. Results will be presented using a tree graph to display the moderating factor(s) investigated, and a ratio showing the number of time evidence for moderation was examined by the total number of investigations.

ETHICS AND DISSEMINATION

The university Human Research Protection Program determined that the proposed scoping review does not qualify as human subject research under federal human subject research regulations (IRB-2023-1656). Results will be published in a peer-reviewed journal and in the form of a one-page summary for extension programme leaders, part of a nationwide Cooperative Extension network.

Assessment tools of the fear of falling: A scoping review

AIM

To comprehensively evaluate and synthesize fear of falling assessment tools and their psychometric properties.

METHODS

The literature in PubMed, Web of Science Core Collection, Cochrane Library, Embase, Google Scholar, CNKI, Wanfang, VIP, and CBM was systematically searched, and the search period was from the establishment of the database to September 1, 2023, and updated on September 1, 2024.

RESULTS

A total of 104 documents covering 19 assessment tools were included. Of the 19 instruments, the Falls Efficacy Scale-International was the most widely used and had been tested for reliability and validity in different countries and populations. A total of 18 studies focused on tool development and validation, and the remaining 86 were related to tool validation.

CONCLUSION

Scientific and reliable assessment instruments for FOF are an important part of future targeted intervention research. The future research direction of tools should be based on local demographic characteristics and qualitative interview results, combined with objective quantitative indicators measured by professional instruments.

Psychological and educational interventions for preventing falls in older people living in the community

BACKGROUND

Older adults are at increased risk of both falls and fall-related injuries. Falls have multiple causes and many interventions exist to try and prevent them, including educational and psychological interventions. Educational interventions aim to increase older people's understanding of what they can do to prevent falls and psychological interventions can aim to improve confidence/motivation to engage in activities that may prevent falls. This review is an update of previous evidence to focus on educational and psychological interventions for falls prevention in community-dwelling older people.

OBJECTIVES

To assess the benefits and harms of psychological interventions (such as cognitive behavioural therapy; with or without an education component) and educational interventions for preventing falls in older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two trials registries to June 2023. We also screened reference lists and conducted forward-citation searching.

SELECTION CRITERIA

We included randomised controlled trials of community-dwelling people aged 60 years and older exploring the effectiveness of psychological interventions (such as cognitive behavioural therapy) or educational interventions (or both) aiming to prevent falls.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. We also explored: number of people falling; people with fall-related fractures; people with falls that required medical attention; people with fall-related hospital admission; fall-related psychological outcomes (i.e. concerns about falling); health-related quality of life; and adverse events.

MAIN RESULTS

We included 37 studies (six on cognitive behavioural interventions; three on motivational interviewing; three on other psychological interventions; nine on multifactorial (personalised) education; 12 on multiple topic education; two on single topic education; one with unclear education type; and one psychological plus educational intervention). Studies randomised 17,478 participants (71% women; mean age 73 years). Most studies were at high or unclear risk of bias for one or more domains. Cognitive behavioural interventions Cognitive behavioural interventions make little to no difference to the number of fallers (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.82 to 1.02; 4 studies, 1286 participants; low-certainty evidence), and there was a slight reduction in concerns about falling (standardised mean difference (SMD) -0.30, 95% CI -0.42 to -0.19; 3 studies, 1132 participants; low-certainty evidence). The evidence is very uncertain or missing about the effect of cognitive behavioural interventions on other outcomes. Motivational interviewing The evidence is very uncertain about the effect of motivational interviewing on rate of falls, number of fallers, and fall-related psychological outcomes. No evidence is available on the effects of motivational interviewing on people experiencing fall-related fractures, falls requiring medical attention, fall-related hospital admission, or adverse events. Other psychological interventions The evidence is very uncertain about the effect of health coaching on rate of falls, number of fallers, people sustaining a fall-related fracture, or fall-related hospital admission; the effect of other psychological interventions on these outcomes was not measured. The evidence is very uncertain about the effect of health coaching, guided imagery, and mental practice on fall-related psychological outcomes. The effect of other psychological interventions on falls needing medical attention or adverse events was not measured. Multifactorial education Multifactorial (personalised) education makes little to no difference to the rate of falls (rate ratio 0.95, 95% CI 0.77 to 1.17; 2 studies, 777 participants; low-certainty evidence). The effect of multifactorial education on people experiencing fall-related fractures was very imprecise (RR 0.66, 95% CI 0.29 to 1.48; 2 studies, 510 participants; low-certainty evidence), and the evidence is very uncertain about its effect on the number of fallers. There was no evidence for other outcomes. Multiple component education Multiple component education may improve fall-related psychological outcomes (MD -2.94, 95% CI -4.41 to -1.48; 1 study, 459 participants; low-certainty evidence). However, the evidence is very uncertain about its effect on all other outcomes. Single topic education The evidence is very uncertain about the effect of single-topic education on rate of falls, number of fallers, and people experiencing fall-related fractures. There was no evidence for other outcomes. Psychological plus educational interventions Motivational interviewing/coaching combined with multifactorial (personalised) education likely reduces the rate of falls (although the size of this effect is not clear; rate ratio 0.65, 95% CI 0.43 to 0.99; 1 study, 430 participants; moderate-certainty evidence), but makes little to no difference to the number of fallers (RR 0.93, 95% CI 0.76 to 1.13; 1 study, 430 participants; high-certainty evidence). It probably makes little to no difference to falls-related psychological outcomes (MD -0.70, 95% CI -1.81 to 0.41; 1 study, 353 participants; moderate-certainty evidence). There were no adverse events detected (1 study, 430 participants; moderate-certainty evidence). There was no evidence for psychological plus educational intervention on other outcomes.

AUTHORS' CONCLUSIONS

The evidence suggests that a combined psychological and educational intervention likely reduces the rate of falls (but not fallers), without affecting adverse events. Overall, the evidence for individual psychological interventions or delivering education alone is of low or very-low certainty; future research may change our confidence and understanding of the effects. Cognitive behavioural interventions may improve concerns about falling slightly, but this may not help reduce the number of people who fall. Certain types of education (i.e. multiple component education) may also help reduce concerns about falling, but not necessarily reduce the number of falls. Future research should adhere to reporting standards for describing the interventions used and explore how these interventions may work, to better understand what could best work for whom in what situation. There is a particular dearth of evidence for low- to middle-income countries.

Chronic stress and functional health in older adults with concerns about falling: a study protocol of a randomized controlled trial with multicomponent exercise intervention (FEARFALL)

BACKGROUND

Maintenance of physical function, mobility, and independent living are important goals for older adults. However, concerns about falling (CaF) play a central role in the vicious cycle of CaF, inflammation, loss of muscle mass, and decreasing physical function ultimately resulting in negative health outcomes. CaF, like other states of chronic stress and anxiety, can be considered as enduring adverse stimuli affecting the stress systems and the inflammatory system. Therefore, the aim of this study is to investigate whether a reduction of CaF leads to a reduction of stress and therefore possibly reduces chronic low-grade inflammation. Understanding the role and directionality of the effects of inflammation on CaF increases our understanding of age-related loss of mobility and physical function.

METHODS

In this study, community-dwelling older adults, aged 70 years and older, will be randomly assigned to either a 4-month, multi-component intervention with exercise training and cognitive-behavioral components or to a sham control group with light stretching exercises, cognitive training, and educational health lectures. For the operationalization of specific CaF, the Falls Efficacy Scale-International will be used. Stress and related psychological symptoms will be monitored using established self-reports and by measuring salivary cortisol. Concentrations of C-reactive protein, interleukin 6, interleukin 10, and tumor-necrosis-factor-alpha, as well as gene expression of selected inflammatory transcripts, will be used as surrogate parameters of the inflammatory status at baseline, after the 4-month intervention and 8-month follow-up.

DISCUSSION

This study will be the first to test whether CaF are related with stress system activity or reactivity or with markers of inflammation in the context of a multi-component intervention with exercise training and cognitive-behavioral components addressing CaF. The reduction of specific CaF or general psychological symptoms should reverse alterations in stress systems, and / or slow down low-grade inflammation. Changes in activity, as well as psychological and biological pathways leading from CaF to muscle loss will be measured, to disentangle the individual contribution to sarcopenia, and to provide an additional pathway to break or slow-down the vicious cycle of CaF and sarcopenia.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00029171 . Registered 22 July 2022.

Association between personality traits and concerns about falling among older patients: the mediating role of subjective age

Background

Older patients are at high risk of falling, and regular assessments of their concerns about falling (CaF) are often recommended. The present study aimed to investigate the association between CaF and personality traits among older patients as well as to elucidate the mediating role of subjective age.

Method

A cross-sectional study was conducted among 407 patients aged over 60 years in a tertiary hospital located in Chengdu, Sichuan Province, from March 2023 to May 2023. Predesigned electronic questionnaires were distributed to collect relevant data. Four different models (both crude and adjusted weighted linear regression models) were constructed based on the confounders. Confounders were gradually put into the models to control for bias and to examine the stability of the correlations. Bootstrap sampling was employed to examine the mediating role of subjective age.

Result

According to the fully adjusted model, neuroticism (β = 0.17, 95% CI: 0.02 to 0.31, p for trend = 0.02), extraversion (β = -0.07, 95% CI: -0.15 to 0.001, p for trend = 0.05), and subjective age (β = 2.02, 95% CI: 1.28 to 2.78, p for trend <0.001) were consistently correlated with CaF. Mediating analysis revealed that extraversion was negatively related with CaF both directly and indirectly, via subjective age [23.2% partial effect, bootstrap 95%CI: -0.024(-0.080, -0.000)]. Higher neuroticism was consistently related to older subjective age (β = 0.002, 95% CI: 0.001 to 0.004, p for trend = 0.006), while higher levels of conscientiousness, openness, and extraversion were consistently correlated with younger subjective age(β = -0.002, p for trend = 0.04; β = -0.003, p for trend = 0.003; β = -0.002, p for trend = 0.0, respectively).

Conclusion

Extraversion and neuroticism were significantly correlated with CaF. Moreover, subjective age partially mediated the relationship between extraversion and CaF. Furthermore, subjective age was found to be associated with both CaF and personality traits. These findings highlighted the important roles of personality traits and subjective age in assessments of CaF and in the development of strategies for preventing falls among older patients.

Impact of Documented Fall-Risk, Self-Reported Health and Confidence to Prevent Falls on Concern About Falling Among Community-Dwelling Older Adults: Secondary Analysis of a Randomized Clinical Trial

Purpose

Individuals identified as high fall risk are expected to have high concern about falling. However, perception and individual factors that influence concern about falling have yet to be thoroughly studied. We aimed to understand factors that influence concern about falling among older adults with increased risk for falling.

Patients and Methods

This was a secondary analysis of a clinical trial among community-dwelling older adults (age ≥65 years old) at high risk for falls (n = 178). Descriptive and regression analyses were used. We analyzed the relationship between participants' baseline concern about falling - categorized into three groups: low (7-8), moderate (9-13), and high (≥14) - and factors that may impact their concern. Exploratory factors included age, sex, self-reported health status and confidence to address fall risks, fall risk scores, and physical performance measures.

Results

Among these individuals, 15.2% reported low concern about falling. On average, individuals in higher concern about falling groups had higher fall risk scores (low [5.7], moderate [6.4], and high [8.0]; p < 0.001). Our regression model showed that the odds of being in a higher concern group increased by 21% for every one unit increase in fall risk score and increased by 67% for every one unit increase toward poorer health rating. Conversely, for every one unit increase in self-reported confidence, the odds of being in a higher concern group decreased by 27.5%.

Conclusion

Knowledge of older adults' fall risk, health status, and concerns about falling can be used to assist in the personalization of fall prevention interventions for a more holistic approach.

Effectiveness of dance interventions for falls prevention in older adults: systematic review and meta-analysis

INTRODUCTION

Fall prevention is a global health priority. Strength and balance exercise programmes are effective at reducing falls. Emerging literature suggests dance is an enjoyable and sociable form of exercise. However, there is little evidence that dance reduces fall incidence.

METHODS

Systematic review and meta-analysis examining effectiveness and cost-effectiveness of dance for falls prevention in older adults. Five databases were searched with no restrictions on publication date or intervention settings. Risk of bias was assessed using variants of Cochrane Risk of bias tools, Mixed-Methods Appraisal and Drummond checklist as appropriate. Certainty of evidence was assessed using GRADE.

RESULTS

Forty-one studies were included (19 RCTs, 13 quasi-experimental, two mixed-method, seven observational studies, 2,451 participants). Five types of dance interventions were identified: ballroom and Latin dance, dance exercise, cultural dance, dance therapy, and low-impact dance. Meta-analysis was only possible for functional outcome measures: Timed-Up-and-Go (dance versus usual care, mean difference (MD) = 1.36; 95% CI -3.57 to 0.85), Sit-to-Stand (dance versus exercise MD = -0.85; 95% CI -2.64 to 0.93: dance versus education MD = -1.64; 95% CI -4.12 to 0.85), Berg Balance Scale (dance versus usual care MD = 0.61; 95% CI -4.26 to 5.47). There was unexplained variance in effects and no significant differences between intervention and control groups. Overall, certainty of evidence was very low; we are uncertain about the effect of dance interventions in reducing falls.

CONCLUSIONS

There is very low certainty evidence for dance as an alternative to strength and balance training if the aim is to prevent falls. No robust evidence on the cost-effectiveness of dance interventions for the prevention of falls was found.

PROSPERO REGISTRATION

CRD42022382908.

The influence of false interoceptive feedback on emotional state and balance responses to height-induced postural threat

Postural threat elicits a robust emotional response (e.g., fear and anxiety about falling), with concomitant modifications in balance. Recent theoretical accounts propose that emotional responses to postural threats are manifested, in part, from the conscious monitoring and appraisal of bodily signals ('interoception'). Here, we empirically probe the role of interoception in shaping emotional responses to a postural threat by experimentally manipulating interoceptive cardiac feedback. Sixty young adults completed a single 60-s trial under the following conditions: Ground (no threat) without heart rate (HR) feedback, followed by Threat (standing on the edge of a raised surface), during which participants received either false heart rate feedback (either slow [n = 20] or fast [n = 20] HR feedback) or no feedback (n = 20). Participants provided with false fast HR feedback during postural threat felt more fearful, reported feeling less stable, and rated the task more difficult than participants who did not receive HR feedback, or those who received false slow HR feedback (Cohen's d effect size = 0.79 - 1.78). However, behavioural responses did not significantly differ across the three groups. When compared to the no HR feedback group, false slow HR feedback did not significantly affect emotional or behavioural responses to the postural threat. These observations provide the first experimental evidence for emerging theoretical accounts describing the role of interoception in the generation of emotional responses to postural threats.

Population-based interventions for preventing falls and fall-related injuries in older people

BACKGROUND

Around one-third of older adults aged 65 years or older who live in the community fall each year. Interventions to prevent falls can be designed to target the whole community, rather than selected individuals. These population-level interventions may be facilitated by different healthcare, social care, and community-level agencies. They aim to tackle the determinants that lead to risk of falling in older people, and include components such as community-wide polices for vitamin D supplementation for older adults, reducing fall hazards in the community or people's homes, or providing public health information or implementation of public health programmes that reduce fall risk (e.g. low-cost or free gym membership for older adults to encourage increased physical activity).

OBJECTIVES

To review and synthesise the current evidence on the effects of population-based interventions for preventing falls and fall-related injuries in older people. We defined population-based interventions as community-wide initiatives to change the underlying societal, cultural, or environmental conditions increasing the risk of falling.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in December 2020, and conducted a top-up search of CENTRAL, MEDLINE, and Embase in January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, trials with stepped-wedge designs, and controlled non-randomised studies evaluating population-level interventions for preventing falls and fall-related injuries in adults ≥ 60 years of age. Population-based interventions target entire communities. We excluded studies only targeting people at high risk of falling or with specific comorbidities, or residents living in institutionalised settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and used GRADE to assess the certainty of the evidence. We prioritised seven outcomes: rate of falls, number of fallers, number of people experiencing one or more fall-related injuries, number of people experiencing one or more fall-related fracture, number of people requiring hospital admission for one or more falls, adverse events, and economic analysis of interventions. Other outcomes of interest were: number of people experiencing one or more falls requiring medical attention, health-related quality of life, fall-related mortality, and concerns about falling.

MAIN RESULTS

We included nine studies: two cluster RCTs and seven non-randomised trials (of which five were controlled before-and-after studies (CBAs), and two were controlled interrupted time series (CITS)). The numbers of older adults in intervention and control regions ranged from 1200 to 137,000 older residents in seven studies. The other two studies reported only total population size rather than numbers of older adults (67,300 and 172,500 residents). Most studies used hospital record systems to collect outcome data, but three only used questionnaire data in a random sample of residents; one study used both methods of data collection. The studies lasted between 14 months and eight years. We used Prevention of Falls Network Europe (ProFaNE) taxonomy to classify the types of interventions. All studies evaluated multicomponent falls prevention interventions. One study (n = 4542) also included a medication and nutrition intervention. We did not pool data owing to lack of consistency in study designs. Medication or nutrition Older people in the intervention area were offered free-of-charge daily supplements of calcium carbonate and vitamin D3. Although female residents exposed to this falls prevention programme had fewer fall-related hospital admissions (with no evidence of a difference for male residents) compared to a control area, we were unsure of this finding because the certainty of evidence was very low. This cluster RCT included high and unclear risks of bias in several domains, and we could not determine levels of imprecision in the effect estimate reported by study authors. Because this evidence is of very low certainty, we have not included quantitative results here. This study reported none of our other review outcomes. Multicomponent interventions Types of interventions included components of exercise, environment modification (home; community; public spaces), staff training, and knowledge and education. Studies included some or all of these components in their programme design. The effectiveness of multicomponent falls prevention interventions for all reported outcomes is uncertain. The two cluster RCTs included high or unclear risk of bias, and we had no reasons to upgrade the certainty of evidence from the non-randomised trial designs (which started as low-certainty evidence). We also noted possible imprecision in some effect estimates and inconsistent findings between studies. Given the very low-certainty evidence for all outcomes, we have not reported quantitative findings here. One cluster RCT reported lower rates of falls in the intervention area than the control area, with fewer people in the intervention area having one or more falls and fall-related injuries, but with little or no difference in the number of people having one or more fall-related fractures. In another cluster RCT (a multi-arm study), study authors reported no evidence of a difference in the number of female or male residents with falls leading to hospital admission after either a multicomponent intervention ("environmental and health programme") or a combination of this programme and the calcium and vitamin D3 programme (above). One CBA reported no difference in rate of falls between intervention and control group areas, and another CBA reported no difference in rate of falls inside or outside the home. Two CBAs found no evidence of a difference in the number of fallers, and another CBA found no evidence of a difference in fall-related injuries. One CITS found no evidence of a difference in the number of people having one or more fall-related fractures. No studies reported adverse events.

AUTHORS' CONCLUSIONS

Given the very low-certainty evidence, we are unsure whether population-based multicomponent or nutrition and medication interventions are effective at reducing falls and fall-related injuries in older adults. Methodologically robust cluster RCTs with sufficiently large communities and numbers of clusters are needed. Establishing a rate of sampling for population-based studies would help in determining the size of communities to include. Interventions should be described in detail to allow investigation of effectiveness of individual components of multicomponent interventions; using the ProFaNE taxonomy for this would improve consistency between studies.

Association Between Concerns About Falling and Risk of Injurious Falls in Older Adults: The Role of Balance Impairment

OBJECTIVES

We aimed to examine the extent to which concerns about falling are associated with the risk of injurious falls in older adults, and to explore the role of balance impairment in this association.

DESIGN

Prospective study with a 5-year follow-up.

SETTING AND PARTICIPANTS

Participants were 1281 people, aged ≥60 years (62.5% women), from the Swedish National Study on Aging and Care in Kungsholmen.

METHODS

Data on injurious falls during 5 years of follow-up was obtained from national registers. Cox and Laplace regression models were applied to examine injurious falls in relation to concerns about falling (binary variable), balance impairment (one-leg balance test), or an indicator variable with 4 mutually exclusive categories based on the presence of concerns about falling and balance impairment.

RESULTS

There was no statistically significant association between concerns about falling and injurious falls in the total sample when adjusting for covariates. We found significant interactions of concerns about falling with balance impairment and age (<70 vs ≥80 years), so that the association between concerns about falling and injurious falls was more evident in people with better balance and the younger-old participants (P < .05). Having only concerns about falling [hazard ratio (HR) 2.06, 95% CI 1.22, 3.48], only balance impairment (HR 2.22, 95% CI 1.38, 3.56), or both (HR 2.35, 95% CI 1.45, 3.82) were associated with an increased risk of injurious falls compared to those with neither concerns about falling nor balance impairment.

CONCLUSIONS AND IMPLICATIONS

Our results suggest that concerns about falling may increase the risk of injurious falls, especially among younger-old people or those without objective balance impairment.

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

BACKGROUND

Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour.

OBJECTIVES

To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies.

SELECTION CRITERIA

This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition.

DATA COLLECTION AND ANALYSIS

Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions.

AUTHORS' CONCLUSIONS

CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

A concept analysis of fear of falling in older adults: insights from qualitative research studies

BACKGROUND

Fear of falling is a persistent concern about falls that commonly occur in older adults. Recently, it has been argued that fear of falling doesn't simply mean a state of low falls efficacy, but is a concept distinct from falls efficacy. However, the two concepts are still indistinguishable. Therefore, it is necessary to understand the unique characteristics of the fear of falling. This study aims to analyze the concept of 'fear of falling' faced by older adults.

METHODS

This study is designed as a concept analysis. A concept analysis was conducted by Walker & Avant's eight-step concept analysis method. A total of 16 pieces of literature were selected by inclusion and exclusion criteria from those published in Pubmed and Scopus between 1993 and 2022 on 8 November 2022.

RESULTS

Two antecedents, four attributes, and five consequences were identified. Apprehension caused by the unpredictable nature of falls, unease related to one's vulnerability, high vigilance-related to the environment, and concern about potential harm after fall events were presented as attributes of fear of falling in older adults. There were two antecedents of fear of falling which were awareness of falls and near falls, and direct/indirect experience about falls and near falls. As consequences of fear of falling, protective effect, activities curtailment, reduction in radius of living, restricted freedom, and limited social activities were reported.

CONCLUSION

It was confirmed that falls and the fear-inducing process were fused to constitute the unique characteristics of the fear of falling. This can be presented as an important basis for future research on the fear of falling or dealing with various aspects of the fear of falling in the clinical field.

Theoretical framework of concerns about falling in older people: the role of health literacy

Adherence and participation can be improved in health programs for older people with concerns about falling. While health literacy empowers older people to have greater control over their health, little is known about the extent to which health literacy influences health behaviours associated with concerns about falling in older people. This study aimed to synthesise current findings on health literacy, concerns about falling and falls to propose a multicomponent theoretical model on health literacy and concerns about falling. The model was developed based on a review of the literature, existing frameworks and models on health literacy and concerns about falling. Existing evidence on the relationship between health literacy and concerns about falling in older people is limited. Evidence from other research areas, however, shows that health literacy is closely related to many of the determinants of concerns about falling. More research is needed to clarify the impact of health literacy on intervention adherence and decision-making processes of older people with concerns about falling. Our model offers a novel perspective on the role of health literacy in health behaviours associated with concerns about falling, suggesting new research directions and providing insights for clinicians to consider health literacy when managing older patients with concerns about falling.