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Falls and Fear of FallingAmong Elderly PersonsLiving in theCommunity:Occupational TherapyInterventionsJ. Elizabeth Walker,Jonathan HowlandKey Words: aged. hip fractures.occupational therapy services. preventivehealth services (community)

Each year, about one third of the population over65 years of age experiences at least onefall (Perry,1982). Assessment of the incidence offalls and theprevalence, intensity, and covariates offear offall-ing among community-based elderlypersons wasconducted through interviews of 115 residents in ahousing development (mean age = 78 years). F ~ r t y -three percent reported havingfallen in recentyears, 32% in the last year. Fear offalling rankedfirst when compared with other common fears. In alogistic regression modelpredicting limitation of ac-tivity independent of risk factors for falling, fear offalling was marginally significant (p = .06). The re-sults of the study show that falls are frequent andfear offalling prevalent among the communitybased elderly. A comprehensive program designedto reduce the risk offalls is presented.

J. Elizabeth Walker, MPH, OTR/I., is Inpatient Coordinatorfor Occupational Therapy, Beth Israel Hospital, 330Brookline Avenue, Boston, Massachusetts 02215.Jonathan Howland, PhD, MPH, is Assistant Professor, BostonUniversity School of Public Health, Boston, Massachusetts.This article was accepted for publication August 1, 1990.

Falls are a common problem among elderly persons, with potentially serious consequences.Each year, about one third of the populationover 65 years of age experiences at least one fall(Perry, 1982). Approximately 85% of these falls occurat home among elderly persons living independently(Tideiksaar, 1987). Although many falls do not resultin serious injury, falls are the sixth leading cause ofdeath among elderly persons (Baker & Harvey, 1985)and a frequent factor in admission to nursing homes.Moreover, there is increasing evidence that many elderly persons are apprehensive about falls, and thisfear of falling may compromise quality of life.

Because occupational therapy's aim is to maximize independent functioning, and because occupational therapy is often a component of postfall rehabilitative care, it is incumbent upon occupationaltherapists to recognize the risk factors for falls and thedegree to which fear of falling can affect mobility andconstrain activities of daily living. In this paper, wepresent an overview of the problems of falls amongthe elderly, report on the results of a pilot study onelderly persons' falls and fear of falling, and discussthe role of occupational therapists in the preventionof falls. Ou r focus is on falls among elderly personsresiding in the community, because changes in demography as well as in the reimbursement methodsemployed by Medicare have resulted in an increasingnumber of elderly persons living independently whothus may be at risk for falls in this setting. Accordingly, there is an increasing number of persons aged65 years and older who could benefit from an enhanced role of occupational therapy in the treatmentand prevention of falls.Literature ReviewThe medical model, in which outcome is related to asingle disease or etiologic factor, is seldom applicableto falls. Instead, a threshold model, in which a number of factors combine to limit a person's overallfunctional status, is more appropriate (Hindmarsh &Estes, 1989). A number of studies have attempted todetermine the intrinsic and extrinsic causes of fallsamong community-based elderly persons (Perry,1985). Although disease processes appear to bestrong determinants for falls in persons over the ageof 75 years, environmental factors appear more commo n in the etiology of falls in the younger elderly(Perry, 1985). Elderly women have consistently beenidentified as being at risk for falls in the home. Fallvictims are often housebound as a result of immobility(Wild, Nayak, & Issacs, 1981) or fear of falling andoften have a history of falls (Kennedy & Coppard,1987). In addition, impaired cognition, the use of sedatives, decreased vision, and the presence of the pal-

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momental (palm-chin) reflex have also been associated with falls among elderly persons living in thecommunity (Tinetti, Speech ley, & Gitner, 1988) Riskfactors for falls are commonly classified into threetypes: IleJIIIl tlctOfS, e n v i r o n m e n r ~ j f ~ c t o r , Qnd rigk-taking behaviors.

Although 75% to 84% of falls do not result inserious injury (Vellas, Cayla, Bocquet, De Pemile, &Albarede, 1987), the consequences of many falls aredevastating. Falls are the leading cause of accidentaldeath in the home (Lamb, Miller, & Mernadez, 1987)About 5% of the falls experienced by elderly personswill result in some type of a fracture (Kennedy &Coppard,1987) Approximately 200,000 hip fracturesamong elderly persons result from falls each year.Fony thousand of these victims die within 6 months,an d another 40,000 require lifelong nursing care(Cobey et ai, 1976) Hip fractures secondary to ne wfalls have been estimated to have cost the UnitedStates approXimately $2 billion in 1980 (Robinson,1984)Pilot StudyTo assess the incidence of falls and the prevalence,intensity, and covariates of fear of falling among thecommunity-based elderly, we interviewed a randomsample of 115 persons aged 62 years or older wh owere residents of an apanment complex for the elderly in Brookline, Massachusetts. All residents hadaccess to a meal del ivery program and the services of aregistered nurse. Fony-two percent of the subjects reponed that they received assistance for shopping,housework, meal preparation, bathing, dressing, or

Table 1Subjects' Demographics and Reported ActivityLevel (N = 115)Category % of Subjects

DEMOGHAPHICSWomen (mean age = 79 years) 76Men (mean age = 77 years) 24Living alone 79Marital statusMarried 12

Divorced 6Widowed 64Separated 1Single 17

ACTIVITY LEVEl.Ever go out on own 86Get out every day 67Altend social functions regularly 57Employed or volunteer 27Wish were more active 44Ever have visitors 92Wish had more visitors 28

Table 2Subjects' Reported Fall Risk Factors% of SubjectsFall Risk factor ____Reponing

Health compared with I)eersExcellent 7Good ') 7Fair 28Poor 8Use eyeglasses 96Always/Most of the time 55

lise Walking aid 38Always/Most of the time 20

Dizzy on arising 31Always/Most of the time 6Pain in muscles, hones, joints 80Always/Most of the time 45

Hold on for support 30Always/Most of the time 13

Difficult to get in and out of bed 16Always/Most of the time 4

lise prescri pt ion med cation 80Use alcohol 43Once a week or more 7

Stand on chair to reach ')6Have grah bars in b,llhroom 8')Breathless ')4Always/Most of the time 23

feeding. Subjects wh o were non-English speaking,deaf, or unable to answer the survey questions due tocognitive deficits were eliminated from th e study,thereby leaVing us with 115 respondents. Twenty-fourpercent of these respondents were men ane! 76% werewomen. Th e mean age of all respondents was 78years; me n and women were comparable with respectto mean age (see Table 1) Th e subjects' reponee! riskfactors for falls are summarized in Table 2.

Fifty-three percent of the respondents reponedhaVing experienced a fall within recent years.Twenty-nine percent reponed having fallen at leastonce during the last year, and 9% reported havingfallen two or more times during the last year. Of thosewho had fallen within the last year, 69% reponedbeing injured as a result of their last fall, 49% requiredmedical attention, 36% reqUired at least 1 day of limited activity, 15% reqUired hospitalization, and 7% hadbroken bones as a result of their last fall.

Th e majority of reponed falls occurred during theearly afternoon (43.6%) and the late afternoon(20.5%), reflecting, most likely, periods of increasedactivity ane! therefore greater exposure to risk; 12.8%fell before lunch; 10.3%, before breakfast; 5.1%, before bed; 5.1%, after waking up during the night; and2.6%, after dinner.Almost half (46%) of the reponed falls occurredin the home. Of these, 15% occurred in the kitchen;16%, in the bedroom; and 15%, in the living room.Interestingly, none of the respondents reponed fallsin the bathroom. Eighty-five percent of the respondents reponed haVing bathroom grab bars. Thus, it

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appears that grab bars were effective in helping residents avoid falls in what could be a hazardous area.

Fear of falling among elderly persons can compromise quality of life by diminishing the sense ofwell being, limiting mobility, and reducing social interaction. Moreover, by constraining movement, fearof falling may itself be a risk factor for falls as a resultof reduced physical conditioning.

Forty-one percent of respondents said that therewere things they would like to do but did not dobecause they were afraid of falling. Thirty-four percent of the respondents reported they were very orsomewhat afraid that they would experience a fall inthe forthcoming year. Fear of falling was the greatestfear among the respondents (25%) when comparedwith other common fears, as follows: fear of robbery(16%), fear of forgetting an important appointment(14%), fear of experiencing financial difficulties(14%), and fear of losing a cherished item (5%)

To further assess the effect of fear of falling, amultivariate logistic regression analysis was used todetermine if fear of falling made a contril,ution tolimitation of activity independent of risk factors forfalling. When regular attendance at social gatheringswas used as a dichotomous dependent variable (57%of the respondents said they were regular attendantsat such gatherings), self-reported health status wasSignificantly associated (p = .01); fear of falling andchronic pain in muscles, joints, or bones were marginally significant (p = .06 and p = .07, respectively);and age, sex, experience of previous falls, use of prescription medications, use of walking aiel, dizzinesson arising, and knOWing someone who had recentlyfallen were not significant.DiscussionThis preliminary study suggests that (a) fear of fallingis a common and intense experience among community-b;lsed elderly persons, even among those withouta histOry of falls, ancl (b ) fear of falling may contributera decreased activity among that population.

The problems of falls and fear of falling amongcommunity-based elderly persons are characteristic ofother problems encountered by gerontic occupational therapists in that (a) falls and fear of falling cancause problems in occupational performance thatcannot be reduced to solely biological or psychological facrars ancl (11) remediation requires an interdisciplinary approach. Like other programs developed bygerontic occupational therapists, the goal of fall intervention is to "achieve a person-environment fit" thatenables the elderly person to function as competentlyas possible (Rogers, 1981, p. 664). A holistic approachto fall prevention in elderly persons considers notonly the biological changes of aging but also the so

cial and environmental forces that may constrain independent community living.

Because most falls involve multiple antecedents,fall prevention interventions are inherently comprehensive. A team approach to fall prevention calls uponthe expertise of occupational therapists, physical therapists, physicians, nurses, and social workers. To address the unique needs of a given person, treatmentplans will be patient specific. Nevertheless, ou r 4years of clinical experience and the literature on fallprevention programs suggest the generic interventioncomponents described below.Education. Because many elderly persons are reluctant to discuss their experience of falls or fear offalling, we must take the initiative in broaching thesubject. Common misconceptions about falling canbe pOinted out. 'In particular, the view that falling is aninevitable consequence of aging should be counteredwith the promotion of the idea that the likelihood offalling can be reduced by awareness of the problemand modification of environmental and behavioralrisk factors. Discussions about falls should be conducted in nonjudgmental, empathetic ways. Th e keyis to engender in the patient a sense of personal control that will stimulate subsequent learning an daction.

Environmental safety. Patients can be assisted inidentifying and eliminating environmental hazards inthe home such as throw rugs, poorly lit areas, andchairs on casters. Home safety checklists such as thosecompiled by the U.S. Consumer Product Safety Commission (986) and Tideiksaar (986) can be used topromote a thorough inspection of a residence.Risk-taking hebaviors. Patients can be taught torecognize risky behaviors associated with falls an dcan help investigate safer approaches to their activities of daily living For example, instead of using astep stool to reach for overhead items, the patient canbe told to place commonly used items in easy-roreach locations_ The difficulties encountered inadopting safer behaviors must be acknowledged. Forexample, an elderly person who needs to purchase anappropriate walking shoe may need financial or personal assistance to do so. Available supports and reinforcements for adopting new behaviors should bepresented with each behavior discussed.Assertiveness training Because elderly personswho hesitate or fail to ask for assistance when necessary may place themselves at risk for falls, they shouldbe taught basic assertiveness skills. Assertiveness canbe defined as the ability to stand up for one's needsand defend one's rights. An elderly person who asksthe landlord to fix a torn carpet in his or her apartmentor one who asks a nearby pedestrian for an arm toassist him or her in stepping down from a curb isdemonstrating appropriate assertive behavior. To be

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assertive, elderly persons must recognize their ownneeds and the irrational ideas they hold, such as th eidea that they must be completely independent an dcompetent. Occupational therapists can use roleplaying to develop such assertiveness skills as beingdirect and using first-person language.

Physicaljitness. Occupational therapists can provide elderly persons with low-risk home exercise programs to maintain or improve physical fitness. Walking is an excellent exercise for th e improvement ofcardiovascular fitness, lower extremity strength, andjoint mobility. A walking program can be readily augmented to include specific exercises developed toimprove upper extremity strength, sitting balance,trunk fleXibility, standing balance, endurance, hipmaneuverability, proprioceptive skills, an d bodyimage. We recommend that exercise programs include both upper and lower extremity exercises thatcan be conducted from either a sitting or standingposition, depending on th e needs and abilities of th epatient.

ConclusionFalls are a common barrier to independent living formany elderly persons. Th e results of ou r pilot studysuggest that fear of falling is a highly prevalent andintense phenomenon among both fallers an d nonfallers aged 65 years and over. Fear of fall ing appearsto contribute to reduced activity independent of otherrisk factors. Occupational therapists working with elderly persons living independently have the opportunity to determine patients' risks for falls an d identifypatients with a fear of falling. Fall prevention programs are indicated for patients at risk for falls orreporting a fear of falling. These programs can include education about falls an d risk-taking behaviors,environmental assessments, assertiveness training,an d physical conditioning exercises_

Although falls have recently been the focus ofincreased attention from the medical community, research on ho w to prevent falls among the elderly isjust beginning. Research is needed to answer suchquestions as (a) Which components of a fall prevention program are most beneficial? (b ) What types ofpatients gain th e most from fall prevention efforts? (c)What physical or psychological characteristics ar epositively associated with fear of faIJing? an d (d )When is the intensity of fear of falling appropriate or

not appropriate among elderly persons? As health careprofessionals concerned with preserving and facilitating the highest possible level of function among patients, occupational therapists are in a unique positionnm only to playa role in th e development an d provision of fall prevention programs but also to contributeto research on fall etiology and the evaluation of theefficacy of fall interventions. ...References

Baker, S. P., & Harvey, A. H (1985) Fall injuries in theelderly. Clinical Geriatric Medicine, ], 501-512.Cobey, ]. c., Cobey, ]. H., Conant, L., Weil, U. H.,Greenwald, W. F., & Southwick, W. o. (1976). Indicationsof recovery from fractures of the hip. Clinical Orthopaedicsand Related Research, 117, 258-262.Hindmarsh,].]., & Estes, E. H. (1989). Falls in olderpeople: Causes and interventions. Archives ofInternal Medicine, ]49,2217-2222.Kennedy, T. E., & Coppard, L. C. (Eds.). (1987) Theprevention of falls in later life: A report of the Kellogg International Work Group on Prevention of Falls in the Elderly.Danish Medical Bulletin, 34, 1-24.Lamb, K., Miller,]., & Mernadez, M. (1987). Falls in theelderly Causes and prevention. Orthopaedic NurSing, 6,45-49.Perry, B. C. (1982). Falls among the elderly living inhigh rise apartments. journal of Family Practice, 14,1069-1073.Perry, B. (1985)- Falls among the elderly: A review ofthe methods and conclusions of epidemiologic studies.journal of the American Geriatrics Society, 30, 367-371.Robinson, E. (1984). An estimate of the yearly cost ofhip fractures in the United States. Baltimore: Johns HopkinsSchool of Hygiene and Public Health.

Rogers, J. C. (1981). The Issue Is-Gerontic occupational therapy. Americanjoumal ofOccupational Therapy,35, 663-666.Tideiksaar, R. (1986) _ Preventing falls: Home hazardchecklists to help olde r patients protect themselves. Geriatrics, 4], 26-28.Tideiksaar, R. (1987). Fall prevention in the home.Topics in Geriatric Rehabilitation, 3, 57-64.Tinetti, M. D_, Speechley, M., & Gitner, S. F. (1988).Risk factors for falls among elderly persons Iiving in thecommunity. Ne w England journal of Medicine, 319,1701-1706.U.S. Consumer Product Safety Commission. (1986).Home safety checklist for older consumers. Washington,DC: Author.

Vellas, B., Cayla, F., Bocquet, H., de Pemile, F., & AI-barede,]. L. (1987). Prospective study of restriction of activity in old people after falls. Age and Ageing, 16, 189-193.Wild, D., Nayak, U. S., & Isaacs, B. (1981). How dangerous are falls in old people at home? British Medicaljournal, 24, 266-268.

February 1991, Volume 45, Number 222