Fear of falling: a hidden burden with or without a history of falls
===================================================================

* Keith D Hill

*   geriatric medicine
*   rehabilitation medicine

**Commentary on:** Makino *et al*. Impact of fear of falling and fall history on disability incidence among older adults: Prospective cohort study. *Geriatric Psychiatry* 2018;33:658-62.

## Implications for practice and research

*   Fear of falling (FOF) is common, even in the absence of recent falls. Health professionals should assess older people who present with falls, near falls or unsteady gait for the presence of FOF, and if identified, exercise or cognitive–behavioural intervention should be considered.

*   Future research should evaluate the effectiveness of interventions to address FOF on preventing or minimising development of incident disability.

## Context

FOF is common, being reported in 20%–85% of people aged >65.1 FOF is often under-reported, and this may be influenced by the method of evaluation. Assessment of FOF can be by asking a single question (eg, are you afraid of falling), often used in large surveys, through to detailed questionnaires evaluating level of FOF during varied activities.1 

## Methods

The purpose of this longitudinal study2 was to determine associations between both FOF and falls on development of disability in a large (n=4329) cohort of cognitively intact community-dwelling older people with no disability at baseline. At baseline participants were asked ‘are you afraid of falling’ with four responses (collapsed into an affirmative response (FOF(+)); or a negative response (FOF(−)), and self-report of falls in the preceding year (fallers denoted as Fall(+), and non-fallers as Fall(−). Presence or absence of disability was assessed using centralised data from the Japanese long-term care insurance system which has a two-stage process: (1) assessment by trained government officials evaluating support needs and (2) review of needs by a certification board. Participants were classified as (1) non-fallers without FOF (Fall(−)/FOF(−)); (2) fallers with no FOF (Fall(+)/FOF(−)); (3) non-fallers with FOF (Fall(−)/FOF(+)) and (4) fallers with FOF (Fall(+)/FOF(+)). Trajectory of incident disability was calculated using Cox proportional hazards regression models between the four classifications, with adjustment for multiple functional covariates.

## Findings

Fourteen per cent fell in the preceding year at baseline and 43% reported FOF. Fifty per cent of participants had no falls or FOF, 8% had both fall/s and FOF, 36% had no falls but had FOF and 6% had falls but no FOF. Over an average 52 months follow-up, almost 10% (n=429) developed incident disability. The Fall(−)/FOF(+) group and the Fall(+)/FOF(+) group both had significantly higher rate of development of incident disability, than the other two groups. The Fall(+)/FOF(−) group did not have increased risk of incident disability after adjusting for covariates.

## Commentary

This study reinforces the high prevalence of FOF in older people and the association with the development of disability. These findings emphasise the need for health professionals to include FOF assessment when assessing fallers, and for intermittent evaluation of older people presenting to health services, in order to identify the high proportion (36% in this study) with FOF who have not fallen in the past 12 months. FOF is not frequently assessed in older people, and if it is, it is often through asking a single question, such as in this study. While this single question can be a useful indicator, it has some limitations because FOF can be situation specific (it can be present in some activities and not in others, and to different levels). Expanded scales have been developed to identify mild or early developing FOF (eg, Modified Falls Efficacy Scale (16 items rated 0–10)1 and abbreviated tools (eg, International Falls Efficacy Scale short form–seven items rated 0–4).3 Early identification is important due to activity curtailment that often accompanies FOF, ultimately associated with reduction in balance and mobility, and increased risk of future falls. Interventions such as (1) balance and mobility training4 5 and (2) cognitive–behavioural therapy have been shown to reduce FOF and to reduce risk of recurrent falls.6 Effective identification and intervention may thereby reduce the risk of development of incident disability.

## Footnotes

*   Competing interests None declared.

*   Patient consent Not required.

*   Provenance and peer review Commissioned; internally peer reviewed.

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