Help patients recover from the fear of falling
It can hinder independence, recovery
Sometimes therapists will find it difficult to motivate elderly patients to regain their strength and mobility after an accident or surgery. Patient recovery may lag behind for many reasons, but one potential cause might surprise clinicians: Patients may be afraid they will fall.
Elizabeth Walker Peterson, MPH, OTR/L, first became intrigued with the idea that a fear of falling is a disability after observing older people who had taken serious falls. "I noticed it was difficult to motivate people to participate in therapy in the hospital because they were very concerned about falling again," says Peterson, who is a clinical assistant professor at the University of Illinois at Chicago. "Fear of falling is a rational response to an event that could conceivably happen to them, and even people who haven’t had a fall have a fear of falling," she says. "If the fear is intense enough, it can lead to activity restriction, and then you get into the vicious cycle of activity curtailment and deconditioning caused by the fear of falling."
Peterson was among researchers at Boston University School of Public Health, the Univer sity of Illinois at Chicago, and several other universities who participated in a randomized, controlled trial that sought to reduce the fear of falling among older adults.
The research led to the development of a program called "A Matter of Balance," which teaches patients greater control and instills confidence in their abilities with the purpose of eliminating their fears of falling. The program, which is administered through the Boston University Roybal Center for Research on Applied Geron tology, was designed for older adults who live independently or in assisted-living facilities, but it also will work in the rehabilitation setting.
The program addresses the fear of falling that many older adults have by providing a group intervention in which participants are taught better communication skills and physical exercises and are given an opportunity to gain insight into their own fear and the actual risk factors of falling.
"It’s very important for health care providers to initiate conversations about the fear of falling, and for them to recognize that even older adults who have not had a fall may have a fear that threatens their sense of well-being and causes activity curtailment," Peterson says.
Here’s an outline of how the fear of falling program works:
• Create a structured group intervention. Older adults meet as a group partly because some parts of the education are interactive and work better in a group setting and partly because the participants give each other support, which has a therapeutic effect. The trial program consisted of eight two-hour sessions, scheduled over four weeks, that delve into a variety of activities geared toward physical, social, and cognitive exercises to help reduce a person’s fear of falling. The program used a variety of instructional activities and devices, including videotapes, lecture, group discussion, mutual problem-solving, role playing, exercise training, assertiveness training, home assignments, and negotiating behavioral changes.
• Focus on cognitive restructuring. Program leaders try to change attitudes about falling, partly through the use of skills training in fall prevention and presenting facts about the incidence of falls and what to do if one falls. "The early sessions in the intervention really focus on changing attitudes before attempting to change behavior," Peterson says.
For example, program leaders work to change participants’ perceived control over their environment by helping them realize they have a greater ability to prevent and handle a fall than they realize and by giving them a more realistic assessment of their failures. (See tips on reducing fall risk and fear of falling, p. 153.)
"Once we help people recognize their attitudes about falling, we try to demonstrate the connections between their attitudes, feelings, and behaviors," Peterson says.
Facilitators also try to help people think more positively. For instance, older people who have lost a great deal of their former physical strength may dwell on the fact that they no longer can walk up a flight of stairs with ease and fearlessness. The facilitator might help them realize that walking up the staircase still is possible as long as they hold onto the handrail for balance.
• Provide exercise training. The program emphasizes how exercise and strength-building help reduce the risk of falling. Therapists or other professionals teach participants exercises that focus on improving balance and strength, such as Tai Chi movements that have been shown to reduce fall risk. Facilitators use wide elastic bands to help people build strength and resistance, and about 30 minutes in some of the sessions are devoted to exercise. "One of our goals is to have them continue to exercise after the intervention is through," Peterson says. "We want them to recognize barriers and recognize how to plan ahead of time to exercise."
• Use a group to build social support. By providing a group setting, facilitators give participants an opportunity to share their concerns with others who have had the same experiences, serving as a support network. Also, the participants offer each other tips for preventing falls and overcoming their fear of falls, and they encourage people who have made changes in their attitudes and behaviors. It’s like a group aerobic class or a support group for people trying to lose weight, where individuals are empowered to give it a little more effort than they would on their own because the people in the group are cheering them on, Peterson says. "The group becomes very important. We look to the group for answers and solutions that have helped their own lives."
For example, facilitators ask participants to assess their own behaviors while group members talk about some activities that concern them. The facilitator steps back and allows the group to discuss those concerns freely, without providing feedback. One person might say that she no longer travels downtown because she is concerned about getting off and on the bus and the crowds worry her. Another group member may respond, "I share those concerns, but I’m not willing to give up going downtown or to the theater, so what I do is go with somebody, or maybe I go downtown weekdays when it’s less crowded."
Facilitators also share ideas, but Peterson says group members often provide the best guidance because they know what works for them.
• Teach assertive communication skills. Often older adults do not know the difference between assertive, aggressive, and passive behaviors, Peterson says. "This is relevant to fall prevention because older adults may be placing themselves at risk when they’re not assertive." For instance, a person might be too intimidated to ask his or her physician about the side effects of various medications. Or older people might be too passive to ask family members to help them remove environmental hazards.
"There are many barriers to older adults talking about falls," Peterson says. "Falls are a loaded issue because they symbolize dependence and increased reliance on others." Unfortunately, when people don’t share their concerns about falling, they fail to seek help in preventing falls.
• Educate about environmental hazards. The program teaches participants, who live in their own homes within an assisted-living facility or on their own, about physical hazards in the home, such as living room extension cords or phone cords that trail across a floor. Other hazards include poor lighting on staircases or bathrooms without grab-bars.
Rehab facilities could teach patients the same tips as part of the educational process before a patient is discharged. "We teach them how to evaluate a space for environmental hazards, and then for homework, they go home and evaluate their own space," Peterson says.
The facilitator helps people think about how to overcome barriers to improving their home’s safety. For example, a person might decide he needs a shower chair but not know how to order one. Or someone who is renting an apartment might be concerned about what the landlord would say about physical changes to the home.
"We work with participants to help them think about what the barriers might be so they can come up with solutions and problem-solve," Peterson says.
Need More Information?
Boston Health Interventions. Telephone: (617) 559-0271. "A Matter of Balance" facilitator fee is $250 for training; the material, including a manual and video, costs $175.
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